Haven of Saguaro Valley

Inspectors wroteBased on clinical record review, staff interviews, and review of the facility policy and procedure, the facility failed to ensure that blood pressure medication was administered in accordance with physician ordered parameters for 1 out of 3 sampled residents (Resident # 1). The deficient practice could result in uncontrolled blood pressure.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure bowel and bladder care was provided for one resident (#3) out of 3 sampled. The deficient practice could result in skin breakdown and possible formation of pressure ulcers.

Inspectors wroteBased on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident was free from abuse. The deficient practice could result in further resident abuse.

Inspectors wroteBased on observation, staff interviews, and facility documentation and policy review, the facility failed to ensure transmission-based precautions and proper hand hygiene was implemented during incontinence care. The sample size was one. The deficient practice could result in transmission of infections to residents.

Inspectors wroteBased on staff interviews and review of facility documentation and policy, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 66 and the sample was 17. The deficient practice could result in resident not provided with advanced care activities to meet their needs.

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to ensure that the responsible party was notified of a fall with injury for one resident (#186). The deficient practice could result in required decisions regarding treatment and care not made timely.

Inspectors wroteBased on clinical record review, staff interviews and review of policy, the facility failed to ensure intervention was implemented to prevent a fall for one resident (#29). The sample size was 19. The deficient practice may result in avoidable accidents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#11) was free from unnecessary pain medications. The deficient practice could result in residents experiencing adverse side effects. Findings Include: Resident #11 was admitted on [DATE] with diagnoses of pubic fracture, pulmonary embolism and hypertension. The care plan dated January 19, 2023 revealed the resident was on opiate medication related to pelvic fracture. Interventions included to administer medications as ordered and to monitor for side effects. Review of the physician order revealed for oxycodone (opioid narcotic) 5 mg (milligram) 1 tablet by mouth every six hours as needed for pain on a scale of 6-10. [...]

Inspectors wroteBased on observations, staff interviews, and review of policy and procedure, the facility failed to ensure that expired supplies and medications were not available for resident use. The census was 85. The deficient practice may result in ineffective treatments and/or in residents receiving the expired medications.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy reviews, the facility failed to implement the care plan for one resident (#53) regarding providing an assistive device. The sample size was 23. The deficient practice could result in residents' needs not being met.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one sampled resident (#241) was provided pain management consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. The deficient practice could result in residents' pain not being managed.

Inspectors wroteBased on observations, clinical record review, resident, family member and staff interviews, and policy review, the facility failed to ensure that a call light was within reach of 1 resident (#50). The sample size was 23. The deficient practice could result in residents not being assisted timely with care.

Inspectors wroteBased on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure one of two sampled residents (#341) and the resident's representative was notified in writing of a transfer/discharge with the required information and failed to send a copy of the notice to the Office of the State Long Term Care Ombudsman. The deficient practice could result in residents and representatives not being informed of their discharge/transfer in writing and the Ombudsman not being providing a copy of the transfer/discharge notices.

Inspectors wrote-Resident #63 admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included chronic pulmonary obstructive disease (COPD) exacerbation, acute and chronic respiratory failure with hypoxia and hypercapnia, and metabolic encephalopathy. An admission assessment dated [DATE] at 5:41 PM revealed resident #63 had experienced shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring). Additionally, the assessment stated that the resident was receiving oxygen via nasal cannula. However, the flow rate was not indicated. Review of the current care plan initiated on February 21, 2022 revealed the resident had altered respiratory status/difficulty breathing related to COPD. The goal was that the resident would have no complications related to shortness of breath. The interventions included providing oxygen as ordered. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident's (#9) drug regimen was free from unnecessary drugs. The sample size was 5. The deficient practice could result in the resident receiving medications that are not necessary.

Inspectors wroteBased on clinical record review, resident, family member and staff interviews, and policy review, the facility failed to ensure that one resident's (#395) medical record was accurately documented regarding advance directives. The sample size was 23. The deficient practice could result in residents having inaccurate records regarding advance directives.

Inspectors wroteBased on personnel record reviews, staff interviews, the Facility Assessment, facility documents, and policy and procedures, the facility failed to provide evidence that 2 of 10 sampled staff (#24 and #15) were provided training on dementia management. The deficient practice could result in staff not being knowledgeable of how to care for and respond to residents with dementia.

Inspectors wroteBased on facility documentation, staff interviews, and policy and procedures, the facility failed to ensure all posted daily nurse staffing data was retained for a minimum of 18 months. The deficient practice could result in posted nurse staffing data not being available for public access and review.