Haven of Globe

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.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

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.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

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.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

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.

Gas, Vacuum, and Electrical Systems Deficiencies

Have a battery powered remote alarm panel in a location accessible by operating personnel.

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. Findings include: Observations on February 12, 2025, the facility failed to maintain a clear path to the exit in the following areas: 1. 100 hall- unattended garbage and laundry cart. 2. 200 hall- unattended linen cart. 3. Isolation cart blocking egress through fire/smoke doors by room 500. The management team confirmed the egress deficiencies during the facility tour and exit conference on February 12, 2025.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff. NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction." NFPA 80 2010 edition, Chapter 5 Section 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. Chapter 19, Section 19.3.6.3 Corridor Doors Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed. Findings include: Observations made while on tour on February 12, 2025, revealed the following: 1. Room 104 the door has a gap along the top and handle side. 2. Room 105 the door has a gap along the top and handle side. 3. Room 107 the door has a gap along the top and handle side. 4. Room 103 the door has a gap along the top. 5. Room 108 the door has a gap along the top. 6. Room 213 the door has a gap along the handle side. 7. Room 211 the door is not latching, no strike plate. 8. Room 210 the door has no strike plate and a gap along the handle side. 9. Room 209 the door has no strike plate and a gap along the handle side. 10. Room 207 the door has no strike plate and a gap along the handle side. 11. Room 206 the door has no strike plate and a gap along the handle side. 12. Room 205 the door has no strike plate and a gap along the handle side. 13. Room 204 the door has no strike plate and a gap along the handle side. 14. Room 203 the door has no strike plate and a gap along the handle side. 15. Door leading to activities does not latch. 16. Room 309 the door has a gap along the handle side. 17. Room 302 the door has a gap along the handle side. 18. Room 307 the door has a gap along the handle side. 19. Room 308 the door has a gap along the handle side. 20. Room 305 the door has a gap along the handle side. 21. Room 505 the door has a gap along the handle side. 22. Room 503 the door has a gap along the handle side. 23. Room 400 the door has a gap along the handle side. 24. Room 604 the door has a gap along the handle side. 25. Room 605 the door has a gap along the handle side. 26. Room 612 the door has a gap along the handle side. 27. Room 614 the door has a gap along the handle side. 28. Room 620 the door has a gap along the handle side. 29. Room 622 the door has a gap along the handle side. 30. Room 628 the door has a gap along the handle side. 31. Room 634 the door has a gap along the han

Based on observation, the facility failed to ensure that all exposed electrical wiring was protected. Failure to ensure exposed wiring could cause accidental damage or possibly a fire, which could cause harm to the patients. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "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, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage." In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage. NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them. Findings include: Observations while on the facility tour on February 12, 2025 revealed in the beauty salon closet a missing light fixture with an exposed electrical wire. The management team confirmed the exposed electrical wire during the facility tour and the exit conference on February 12, 2025.

Violation cited

Violation cited

Violation cited

Violation cited

Based 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. Findings include: Regarding residents #1 and #2: -Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. The quarterly MDS (minimum data set) assessment dated March 25, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors. The progress notes dated April 19, 2024 documented an incident note that revealed CNA reported that resident #1 was struck by another resident and that the patients were separated from each other. The note further states resident #1 had no marks on her and denied pain. Appropriate staff and providers notified of the incident. The provider notes dated April 20, 2024 revealed resident #1 reported no complaints of right shoulder pain due to being punched by a resident. Per the provider note staff were to monitor pain and level of consciousness (LOC). -Resident #2 was admitted to the facility March 14, 2016 with diagnosis including dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, mild. A care plan initiated in April 2024 revealed the resident had a focus for use of mood stabilizer medication (Depakote) r/t dementia with behaviors and potential to demonstrate physical behaviors hitting others r/t Anger, Dementia, Poor impulse control, physical behaviors. Interventions included to Give mood stabilizer medications ordered by physician. Monitor/document side effects and effectiveness, target symptoms/Behavior Tracking:(mood swings) and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. The quarterly MDS (minimum data set) assessment dated April 2, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the interview. Further review of the MDS revealed a diagnosis for dementia with no indicators for behaviors. The progress notes dated April 19, 2024 revealed resident #2 struck ano

Based 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. Findings include: Regarding residents #1 and #2: -Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. The quarterly MDS (minimum data set) assessment dated March 25, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors. The progress notes dated April 19, 2024 documented an incident note that revealed CNA reported that resident #1 was struck by another resident and that the patients were separated from each other. The note further states resident #1 had no marks on her and denied pain. Appropriate staff and providers notified of the incident. The provider notes dated April 20, 2024 revealed resident #1 reported no complaints of right shoulder pain due to being punched by a resident. Per the provider note staff were to monitor pain and level of consciousness (LOC). -Resident #2 was admitted to the facility March 14, 2016 with diagnosis including dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, mild. A care plan initiated in April 2024 revealed the resident had a focus for use of mood stabilizer medication (Depakote) r/t dementia with behaviors and potential to demonstrate physical behaviors hitting others r/t Anger, Dementia, Poor impulse control, physical behaviors. Interventions included to Give mood stabilizer medications ordered by physician. Monitor/document side effects and effectiveness, target symptoms/Behavior Tracking:(mood swings) and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. The quarterly MDS (minimum data set) assessment dated April 2, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the interview. Further review of the MDS revealed a diagnosis for dementia with no indicators for behaviors. The progress notes dated April 19, 2024 revealed resident #2 struck ano

Based 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). Findings include: Resident #21 was admitted on November 20, 2023 and discharged November 23, 2024 with diagnoses chronic obstructive pulmonary disease, unspecified, unspecified asthma, uncomplicated, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, unspecified symptoms and signs involving cognitive functions and awareness, legal blindness, as defined in USA). Review of the quarterly Minimum Data Set (MDS) dated October 31, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating resident's cognitive status moderately impaired. Further review of the MDS revealed resident receiving oxygen therapy. Review of the Care Plan date-initiated March 3, 2023 revealed resident receiving oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD). Interventions included when eating, oxygen must still be given to the resident but in a different manner (e.g., changing from mask to nasal cannula). Return resident to usual oxygen delivery method after the meal and monitor for signs and symptoms of respiratory distress. A physician's order dated March 8, 2023 included an order for oxygen at 3 liters per minute as needed to keep saturation level above 90%. every shift for Oxygen Therapy A physician's order dated September 20, 2023 included an order for oxygen at 3 liters per minute via NC. May titrate as needed to keep saturation lever greater than 90%. every shift for oxygen therapy. A physician's order dated November 20, 2023 included an order for oxygen at 1-5 liters per minute as needed to keep saturation level above 90%. every shift for oxygen therapy related to chronic obstructive pulmonary disease, unspecified (j44.9) This order was transcribed onto the MAR (medication administration record) for November 2024 and revealed that the resident had O2 sat levels of greater than 90% at 2 liters per minute. The nursing progress note dated November 23, 2024 revealed that CNA (Certified Nursing Assistant) was being taking resident #21 to breakfast, when stopped by another CNA due to resident being slumped over in her wheelchair and leaning to the left side. This nurse was called to the 500 hallway by CNA who informed resident did not have her oxygen on, breathing was labored and uneven. VS (vital stats) were taken, Resident #21 VS: 172/74, P-122, R-22, T-98.9, oxygen was at 57% RA. Resident's eyes were glassy and watery, resident's breathing was labored, oxygen VI simple mask was placed on resident with oxygen turned on to 10 L. Resident was noncoherent, speech was garbled and breathing continues to be labored, resident was taken to her room, assisted by two CNA's into bed, oxygen turned on and VS continued to monitor, called 911 for transport to hospital. Further review of the progress notes revealed an e