Haven Health Prescott, LLC

Violation cited

The facility failed to ensure that PASARR Level II is completed.Number of residents sampled: 1Number of residents cited: 1

Violation cited

Violation cited

Violation cited

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Violation cited

Violation cited

Violation cited

Violation cited

Based on observation the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency. NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress there from, or visibility thereof. Observations made while on tour on August 20, 2024, revealed the facility failed to maintain a clear path to the exit in the following area: 1) Various items stored along the path of egress leading from the laundry room to a public way. The management team confirmed during the exit conference conducted on August 20, 2024, the above-listed exit pathways was restricted.

Based on observation the facility failed to ensure properly rated doors were protecting hazardous areas. Failing to have properly rated doors and maintaining the self-closing hardware on the door and frame to a hazardous room could cause harm to patients in a time of a fire if the door does not close and latch secure. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Chapter 8, 8.7.1.1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: 1. Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 2. Protecting the area with automatic extinguishing systems in accordance with Section 9.7 3. Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.7.1.3 Doors in barriers required to have a fire-resistance rating shall have a minimum 3/4-hour fire-protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2. .. Findings include: Observations made while on tour on August 20, 2024, revealed the following; 1) Cut out in fire wall for ice machine in the kitchen. 2) Holes in the smoke barrier in the exit corridor of the kitchen. During the exit conference on August 20, 2024, the above findings were again acknowledged by the management team.

Based on observation and interviews the facility failed to provide automatic sprinkler protection for the roof overhang while allowing items constructed of combustible material to be stored under them. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7 Exterior roofs, Canopies, Porte-Cochers, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3 , or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies, Porte-cocheres, balconies decks, or similar projections exceeding 4 ft in width. Findings include: Observations made while on tour on August 20, 2024, revealed the following: 1) items constructed of combustible materials, consisting of cardboard and plastics, being stored under a non-sprinklered overhang near the covered patio. 2) items constructed of combustible material, consisting of cardboard and plastics, being stored under a non-sprinklered overhang near the laundry room exit. During the exit conference on August 20, 2024, the above finding was acknowledged by the management staff.

Based on observation the facility failed to provide protection from electrical shock by ensuring electrical panels are secure. Failing to protect energized electrical equipment or wiring can cause a shock or fire. A fire could cause harm to the residents and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.5.1.1 or Chapter 19, Section 19.5.1.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 "National Electrical Code. NEC, 1999, 2011 Edition, Article 110 Requirements for Electrical Installations, "110.12(B) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating." Findings include: Observations made while on tour on August 20, 2024, revealed the following electrical panel door latches were inoperable: 1) Electrical panels in the maintenance shop (4 panels) 2) Electrical panel in the kitchen 3) Electrical panel outside room 123 During the exit conference on August 20, 2024, the above findings were again acknowledged by the management team.

Based on observation the facility allowed oxygen cylinders to be stored on selves constructed of combustible material. Allowing oxygen cylinders to be stored near combustible materials could cause harm to the patients and/or staff during a fire. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.3 Cylinder and Container Storage Requirements. 11.3.2 Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour Findings include: Observations made while on tour on August 20, 2024, revealed multiple oxygen cylinders being stored on wooden shelves in the oxygen closet outside room 110. During the exit conference on August 20, 2024, these findings were again acknowledged by the management staff.

Based on resident and staff interviews, clinical records review and facility policy, the facility failed to ensure one resident (#34) was not physically abused by another resident (#3). The deficient practice could result in residents being physically injured. Findings include: - Resident #34 was admitted to the facility on January 25, 2023 with diagnosis that included unspecified dementia, unspecified severity, with other behavioral disturbance, chronic obstructive pulmonary disease, unspecified, unspecified psychosis not due to a substance or known physiological condition. The care plan initiated and revised on August 9, 2023 revealed a care plan that stated resident #34 had behavior problem related to refusal of medications, hallucinations, and impaired cognitive function. Review of the facility five-day report submitted on September 19, 2023 documented an interview with resident #34 who stated "she scratched me as I rolled by" referencing resident #3. The report also documented no past encounters with the alleged perpetrator, resident #3. Further interviews with staff documented "resident grabs out." In a progress note dated September 19, 2023 at 09:25 AM the Director of Nursing (DON/ staff #13)documented that the resident's family was notified of a small skin tear to left elbow after a resident interaction. In a progress note dated September 20, 2023 at 4:11 PM, Medical Provider (Staff #106), completed a psychiatric evaluation, documenting that resident #34 was alert and confused, resistive, paranoid at times. Delusions and hallucinations have been chronically noted. Overall psychiatric symptoms have improved over the last number of weeks as her compliance with her medications have improved. Staff #106 also diagnosed and assessed resident #34 with a skin tear of elbow without complication. Review of the quarterly Minimum Data Set (MDS) assessment dated November 3, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 11 which showed resident had moderate cognitive impairment. - Resident #3 was admitted to the facility on April 11, 2022 with diagnoses that included vascular dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, schizophrenia, unspecified, personal history of traumatic brain injury. Review of the annual MDS dated July 20, 2023 showed that a BIMS was not conducted, with staff unable to assess her cognition due to her being rarely or never understood. Staff assessed her to be severely cognitively impaired. Further review of the MDS revealed physical behavioral symptoms directed towards others such as, scratching, grabbing. Other physical behavioral symptoms not directed towards others were also identified, such as hitting or scratching self. Review of her care plan initiated on August 2, 2023 included a care plan related to resident's altered thought process related to her diagnosis of organic brain damage, vascular dementia

Based on observation, 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 (#1) out of fourteen sampled residents, regarding bowel care. The deficient practice could result in excessive discomfort for the resident. Findings include: Resident #1 was admitted to the facility on July 10, 2024 with diagnoses that included paroxysmal atrial fibrillation, unspecified dementia, injury of conjunctiva and corneal abrasions of both eyes, and muscle weakness. Review of physician orders revealed an order dated July 11, 2024 for implementing a routine bowel care 3 step program if the resident did not have a bowel movement in 3 days. Review of the progress notes revealed multiple entries from July 15, 2024 to July 26, 2024 from the Nurse Practitioner (NP) that claim the resident had no constipation or abdominal pain, indicating that the NP was unaware of any constipation issues during this time. Review of the physician order dated July 16, 2024 revealed that 30 mL of Milk of Magnesia Oral Suspension could be given as needed for constipation daily. Review of the Minimum Data Set (MDS) dated July 17, 2024 revealed that the resident is always incontinent of bowel, and constipation was present. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. Review of the facility document titled, TeamHealth Standing Medical Orders, revealed that staff had standing orders which allowed them to address constipation. These orders stated that if the resident had no bowel movement in the last 3 days to order 1 dose of Milk of Magnesia 30mL. If no results by the next morning, the orders instruct to give a Dulcolax suppository. If this is ineffective within 2 hours, the standing orders instruct to give a fleet enema. If these interventions are still ineffective, the staff are instructed to call the provider for further orders. Review of the Bowel Movement Task revealed no documented bowel movements from July 18, 2024 until July 23, 2024 at 9:51PM. Review of the Medication Administration Record (MAR) for July 2024 revealed that Milk of Magnesia was administered on July 23, 2024 at 09:07AM after over 5 days without a documented bowel movement. The resident proceeded to finally have a bowel movement on July 23,2024 at 9:51PM. Review of the care plan entry dated July 23, 2024 revealed a focus that identified the resident has constipation related to decreased mobility and medication side effects. The goal for this entry was that the resident will have a normal bowel movement at least every 3 days. The care plan interventions included following facility bowel protocol for bowel management and keeping the physician informed of any problems. Further review of the Bowel Movement Task revealed no documented bowel movement from July 24, 2024 until July 28, 2024 at 1:46 PM. Revi

Based on resident and staff interviews, clinical records review and facility policy, the facility failed to ensure one resident (#34) was not physically abused by another resident (#3). Findings include: - Resident #34 was admitted to the facility on January 25, 2023 with diagnosis that included unspecified dementia, unspecified severity, with other behavioral disturbance, chronic obstructive pulmonary disease, unspecified, unspecified psychosis not due to a substance or known physiological condition. The care plan initiated and revised on August 9, 2023 revealed a care plan that stated resident #34 had behavior problem related to refusal of medications, hallucinations, and impaired cognitive function. Review of the facility five-day report submitted on September 19, 2023 documented an interview with resident #34 who stated "she scratched me as I rolled by" referencing resident #3. The report also documented no past encounters with the alleged perpetrator, resident #3. Further interviews with staff documented "resident grabs out." In a progress note dated September 19, 2023 at 09:25 AM the Director of Nursing (DON/ staff #13)documented that the resident's family was notified of a small skin tear to left elbow after a resident interaction. In a progress note dated September 20, 2023 at 4:11 PM, Medical Provider (Staff #106), completed a psychiatric evaluation, documenting that resident #34 was alert and confused, resistive, paranoid at times. Delusions and hallucinations have been chronically noted. Overall psychiatric symptoms have improved over the last number of weeks as her compliance with her medications have improved. Staff #106 also diagnosed and assessed resident #34 with a skin tear of elbow without complication. Review of the quarterly Minimum Data Set (MDS) assessment dated November 3, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 11 which showed resident had moderate cognitive impairment. - Resident #3 was admitted to the facility on April 11, 2022 with diagnoses that included vascular dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, schizophrenia, unspecified, personal history of traumatic brain injury. Review of the annual MDS dated July 20, 2023 showed that a BIMS was not conducted, with staff unable to assess her cognition due to her being rarely or never understood. Staff assessed her to be severely cognitively impaired. Further review of the MDS revealed physical behavioral symptoms directed towards others such as, scratching, grabbing. Other physical behavioral symptoms not directed towards others were also identified, such as hitting or scratching self. Review of her care plan initiated on August 2, 2023 included a care plan related to resident's altered thought process related to her diagnosis of organic brain damage, vascular dementia and need for antipsychotic medication as exhibited by her combative behavi

Based on observation, 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 (#1) out of fourteen sampled residents, regarding bowel care. Findings include: Resident #1 was admitted to the facility on July 10, 2024 with diagnoses that included paroxysmal atrial fibrillation, unspecified dementia, injury of conjunctiva and corneal abrasions of both eyes, and muscle weakness. Review of physician orders revealed an order dated July 11, 2024 for implementing a routine bowel care 3 step program if the resident did not have a bowel movement in 3 days. Review of the progress notes revealed multiple entries from July 15, 2024 to July 26, 2024 from the Nurse Practitioner (NP) that claim the resident had no constipation or abdominal pain, indicating that the NP was unaware of any constipation issues during this time. Review of the physician order dated July 16, 2024 revealed that 30 mL of Milk of Magnesia Oral Suspension could be given as needed for constipation daily. Review of the Minimum Data Set (MDS) dated July 17, 2024 revealed that the resident is always incontinent of bowel, and constipation was present. The MDS also revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. Review of the facility document titled, TeamHealth Standing Medical Orders, revealed that staff had standing orders which allowed them to address constipation. These orders stated that if the resident had no bowel movement in the last 3 days to order 1 dose of Milk of Magnesia 30mL. If no results by the next morning, the orders instruct to give a Dulcolax suppository. If this is ineffective within 2 hours, the standing orders instruct to give a fleet enema. If these interventions are still ineffective, the staff are instructed to call the provider for further orders. Review of the Bowel Movement Task revealed no documented bowel movements from July 18, 2024 until July 23, 2024 at 9:51PM. Review of the Medication Administration Record (MAR) for July 2024 revealed that Milk of Magnesia was administered on July 23, 2024 at 09:07AM after over 5 days without a documented bowel movement. The resident proceeded to finally have a bowel movement on July 23,2024 at 9:51PM. Review of the care plan entry dated July 23, 2024 revealed a focus that identified the resident has constipation related to decreased mobility and medication side effects. The goal for this entry was that the resident will have a normal bowel movement at least every 3 days. The care plan interventions included following facility bowel protocol for bowel management and keeping the physician informed of any problems. Further review of the Bowel Movement Task revealed no documented bowel movement from July 24, 2024 until July 28, 2024 at 1:46 PM. Review of the nursing documentation titled, Daily Skilled Evaluation - Nursing, on