Haven of Douglas

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Resident Rights Deficiencies

Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries.

Violation cited

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the rights of one resident (# 2) to be free from abuse by another resident (# 1). The deficient practice could result in other residents being abused.Â

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to protect the resident's (Resident # 2) right to be free from physical abuse by another resident (Resident # 1). The deficient practice could result in other residents being abused.Â

Violation cited

Based on observation, interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure speech therapy services were provided for one resident (#8) when indicated.Â

Based on interviews, review of clinical record, and review of facility policy, the facility failed to maintain highest practicable well-being by failing to ensure a physician order was followed for one resident (#1) regarding a laboratory order.Findings include:

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that medications were administered as prescribed for one resident (#24).  Findings included:

Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that an allegation of exploitation for one resident (#24) was reported and investigated. The deficient practice could result in residents be exploited. Findings include:Â

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#56) was afforded privacy during a medical consultation. The deficient practice could result in residents' rights to privacy not being respected. Findings included: Â

Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to ensure that an allegation of exploitation for one resident (#24) was reported and investigated. The deficient practice could result in continued exploitation of residents.  Findings include:Â

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that medications were administered as prescribed for one resident (#24). The deficient practice could impact the health and wellbeing of the residents.  Findings included:

Based on observations, staff interviews and record review, the facility failed to provide an ongoing activity program that provided activities to meet the individual interests and needs to enhance the quality of life for one resident (#12). The deficient practice could result in resident isolation and decreased quality of life.Findings included:

Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure a physician order was followed for one resident (#1) regarding a laboratory order. The deficient practice could lead to diagnostic testing not being completed and a missed diagnosis.Findings include:

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that food items were stored and prepared under sanitary condition; and failed to ensure that expired food items were discarded. The deficient practice could result in unsafe food storage, placing residents at risk for foodborne illnesses.Findings include:Â Â

Based on observation, interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure speech therapy services were provided for one resident (#8) when indicated. The deficient practice could lead to residents not receiving rehabilitative services when indicated to assist in reaching their highest practicable level of function.  Findings include:

Based on observations, resident and staff interviews and facility policy review, the facility failed to ensure the environment was free from pests. The deficient practice could result in the spread of germs.   Findings included:Â

The facility failed to ensure that one resident (#56) was afforded privacy during a medical consultation.

Based on observations, staff interviews and record review, the facility failed to provide an ongoing activity program that provided activities to meet the individual interests and needs to enhance the quality of life for one resident (#12). Findings included:

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that food items were stored and prepared under sanitary condition; and failed to ensure that expired food items were discarded. Findings include:Â

Based on observations, resident and staff interviews and facility policy review, the facility failed to ensure the environment was free from pests.Findings included:Â