Haven of Flagstaff

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

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

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Nutrition and Dietary Deficiencies

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

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based 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. Findings include: Resident #3 was admitted on January 6, 2021 with diagnosis including venous insufficiency (chronic-peripheral), pressure ulcer of the left heel (unstageable), pressure ulcer of the right heel (unstageable), acute posthemorragic anemia and cellulitis of the left lower limb. A review of the discharge MDS (minimum data set) dated March 10, 2021 revealed no BIMS (brief interview of mental status) score. A review of the physician orders revealed orders for daily wound care to both right/ left heels and posterior right/ left calf. Orders were further observed for physical and occupational therapy. An order dated March 10, 2021 was also observed for a consult for heel debridement. A review of the care plan revealed that the resident had a DTI (deep tissue injury) to bilateral heels and had the potential for further pressure ulcer development due to decreased mobility. The noted intervention included to access, record and monitor wound healing weekly and as necessary. It further noted that length, depth and width would be measured when possible and that all assessments would be documented. The care plan further revealed that the resident had limited mobility due to right hand and bilateral lower extremity contractures. The intervention included referral to physical and occupational therapy as well as monitoring and documentation of contractures forming or worsening. The electronic health record for the resident revealed a time span greater than 7-days for pressure ulcer documentation and assessment for the following assessments: January 25, 2021, February 4, 2021 and February 27, 2021. An interview was conducted on October 22, 2024 with staff #115, LPN (licensed practical nurse). Staff #115 stated that that skin assessments are conducted weekly and documented in the electronic health record. She stated that the risk for not completing the assessment or not completing it timely would include not knowing what is going on with the resident in relationship to wound care or the wound worsening. An interview was conducted on October 23, 2024 at 10:30 A.M. with staff #72 (ADON-assistant director of nursing and wound care nurse). Staff #72 stated that upon admission, residents with wounds are placed on weekly wound care rounds with the physician or nurse practitioner. She stated that assessments are conducted weekly but sometimes more often contingent on what is going on with the pressure ulcer. Staff #72 stated that the risk for not having assessments completed weekly would be contingent on the resident's comorbidities. She stated the facility now has a program in place called PUP (pressure ulcer prevention) and that this has been very helpful in reducing the number of facility acquired pressure

Based 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. Findings include: -Regarding resident #1 Resident #1 was admitted on December 30, 2020 with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection. A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. -Regarding resident #2 Resident #2 was admitted on January 2, 2021 with diagnosis including unspecified fracture of right femur, repeated falls, unspecified dementia, type 2 diabetes, monoplegia of upper limb, facial weakness, other cerebral infarction due to occlusion or stenosis. A review of the progress notes revealed an entry, that on January 28, 2021 an altercation took place between resident #1 and #2. It was noted that both residents were sitting in their wheelchairs prior to the altercation. It was further noted that a PTA (physical therapy assistant) was maneuvering resident #2 around the dining table and upon passing resident #1, resident #2 starting hitting resident #1 with her left upper extremity. It was noted that resident #2 kept hitting resident #1 and then resident #1 starting hitting back in self-defense. Staff (PTA) alerted other staff to the incident and the residents were separated. It was noted that the residents were assessed for injuries and none were present. The progress notes further revealed that an LPN (Licensed Practical Nurse/ staff #22) notified the previous ADON (Assistant Director of Nursing) and he called the Arizona State Board of Nursing, leaving a voicemail regarding the incident and that case managers and family members were notified. However, there is no documented evidence that the incident was reported to the state survey agency. An interview was conducted on October 22, 2023 at 2:15 P.M. with CNA (certified nursing assistant/ Staff #18). Staff #18 stated that abuse could be mental, financial, verbal, neglect or physical. She stated that the facility has annual training but also provides monthly training refreshers. Staff #18 stated that if abuse is observed between residents, the first thing that is done is to physically separate the residents and ensure their safety. Residents may need to be moved to another room, if they were sharing a room. She further stated that once residents are safe, notifications and an incident report would occur and that these are time sensitive and would need to happen right away. Stated that she had received training on abuse and behavioral health. A telephonic interview

Based 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). Findings include: -Regarding resident #1 Resident #1 was admitted on December 30, 2020 with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection. A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. -Regarding resident #2 Resident #2 was admitted on January 2, 2021 with diagnosis including unspecified fracture of right femur, repeated falls, unspecified dementia, type 2 diabetes, monoplegia of upper limb, facial weakness, other cerebral infarction due to occlusion or stenosis. A review of the progress notes revealed an entry, that on January 28, 2021 an altercation took place between resident #1 and #2. It was noted that both residents were sitting in their wheelchairs prior to the altercation. It was further noted that a PTA (physical therapy assistant) was maneuvering resident #2 around the dining table and upon passing resident #1, resident #2 starting hitting resident #1 with her left upper extremity. It was noted that resident #2 kept hitting resident #1 and then resident #1 starting hitting back in self-defense. Staff (PTA) alerted other staff to the incident and the residents were separated. It was noted that the residents were assessed for injuries and none were present. The progress notes further revealed that an LPN staff#22 notified the previous ADON and he called the Arizona State Board of Nursing, leaving a voicemail regarding the incident and that case managers and family members were notified; however, there is no documented evidence that the incident was reported to the state survey agency. Given that the incident occured in 2021, several of the staff members who witnessed the incident are no longer with the facility An interview was conducted on October 22, 2023 at 2:15 P.M. with staff #18 CNA (certified nursing assistant). Staff #18 stated that abuse could be mental, financial, verbal, neglect or physical. She stated that the facility has annual training but also provides monthly training refreshers. Staff # stated that if abuse is observed between residents, the first thing that is done is to physically separate the residents and ensure their safety. Residents may need to be moved to another room, if they were sharing a room. She further stated that once residents are safe, notifications and an incident report would occur and that these are time sensitive and would need to happen right away. A telephonic i

Based 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. Findings include: Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents. -Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism. The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment. A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off. Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night. A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive. A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents. A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound. A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse. Despite documentation of resident #46 slapping or swatting resident #71, there was no evi

Based 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. Findings include: Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents. -Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism. The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment. A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off. Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night. A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive. A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents. A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound. A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse. In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated

Based 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. Findings include: Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents. -Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism. The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment. A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off. Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night. A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive. A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents. A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound. A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on

Based 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. Findings include: Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents. -Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism. The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment. A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off. Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night. A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive. A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents. A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound. A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse. In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps anot