Deficiencies (last 5 years)
Deficiencies (over 5 years)
13.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
262% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
77% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the administration of blood pressure medication to a resident, specifically to determine if medications were administered according to physician-ordered parameters.
Complaint Details
The complaint investigation found that the medication Midodrine was administered outside of physician parameters on multiple occasions, including December 5, 10, 12, 15, and 21, 2025. Staff interviews confirmed errors in medication administration documentation and practice. The issue was substantiated with findings of medication given despite systolic blood pressure above 140.
Findings
The facility failed to ensure that blood pressure medication (Midodrine) was administered in accordance with physician orders for 1 out of 3 sampled residents. The medication was given despite systolic blood pressure readings above the ordered threshold, potentially causing uncontrolled blood pressure.
Deficiencies (1)
Failure to administer blood pressure medication according to physician ordered parameters, resulting in medication given when systolic blood pressure was above 140.
Report Facts
Medication administrations outside parameters: 5
Resident sample size: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #116 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration errors and documentation |
| Staff #103 | Director of Nursing (DON) | Interviewed regarding medication administration policies and review of findings |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to administer blood pressure medication according to physician-ordered parameters.
Complaint Details
The complaint investigation found that the medication Midodrine was administered outside of physician-ordered parameters on multiple occasions, with staff admitting errors in documentation and administration. The Director of Nursing confirmed the order parameters and acknowledged documentation inconsistencies.
Findings
The facility failed to ensure that Midodrine HCL was administered in accordance with physician orders for one out of three sampled residents, resulting in medication being given outside of prescribed blood pressure parameters, which could lead to uncontrolled blood pressure.
Deficiencies (1)
Failure to administer Midodrine HCL according to physician-ordered parameters for orthostatic hypotension, resulting in medication given when systolic blood pressure was above 140.
Report Facts
Residents sampled: 3
Residents affected: 1
Medication doses administered outside parameters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #116 | Licensed Practical Nurse (LPN) | Admitted to medication administration errors and documentation mistakes related to Midodrine |
| Staff #103 | Director of Nursing (DON) | Reviewed medication orders and administration records, confirmed policy and acknowledged documentation issues |
Inspection Report
Census: 86
Capacity: 112
Deficiencies: 1
Date: May 27, 2025
Visit Reason
Life Safety Code Survey found noncompliance with corridor door requirements and fire safety standards.
Findings
Life Safety Code Survey found noncompliance with corridor door requirements and fire safety standards.
Deficiencies (1)
Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke or fire
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to provide adequate bowel and bladder care for a resident, which could result in skin breakdown and pressure ulcers.
Complaint Details
The complaint investigation found that bowel and bladder care was not consistently provided or documented for resident #3, with substantiated risk of skin breakdown and pressure ulcers.
Findings
The facility failed to ensure bowel and bladder care was provided for one resident (#3) out of 3 sampled, with inconsistent documentation and evidence that care was not consistently performed as required, posing a risk of skin breakdown and pressure ulcers.
Deficiencies (1)
Failure to provide and document bowel and bladder care for resident #3, risking skin breakdown and pressure ulcers.
Report Facts
Residents sampled: 3
Residents affected: 1
Dates of care documented: 3
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA), staff #56 | Interviewed regarding bowel and bladder care documentation and practice | |
| Registered Nurse (RN), staff #1 | Interviewed regarding documentation expectations for bowel and bladder care | |
| Director of Nursing (DON), staff #41 | Interviewed regarding inconsistent documentation and risk of skin breakdown |
Inspection Report
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to bowel and bladder care for residents, specifically focusing on one resident (#3) out of three sampled.
Findings
The facility failed to ensure adequate bowel and bladder care was provided to resident #3, which could result in skin breakdown and pressure ulcers. Documentation of care was inconsistent and incomplete, indicating that care may not have been provided as required.
Deficiencies (1)
Failure to ensure bowel and bladder care was provided for one resident (#3) out of 3 sampled, risking skin breakdown and pressure ulcers.
Report Facts
Residents sampled: 3
Residents affected: 1
Dates of care documented: 3
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (staff #56) | Interviewed regarding bowel and bladder care documentation and practices | |
| Registered Nurse (staff #1) | Interviewed regarding documentation expectations for bowel and bladder care | |
| Director of Nursing (staff #41) | Interviewed regarding inconsistencies in bowel and bladder care documentation |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 1
Date: Mar 11, 2025
Visit Reason
Complaint survey citing abuse-related deficiency.
Complaint Details
Investigation of intakes AZ00212850 and SF00115515
Findings
Complaint survey citing abuse-related deficiency.
Deficiencies (1)
R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3.a. Abuse
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of intakes AZ00221683 and AZ00221765
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of intakes AZ00219762, AZ00212917, AZ00212898
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Sep 9, 2024
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of intake AZ00215652
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Jun 19, 2024
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of intakes AZ00211933, AZ00211807, AZ00206737, AZ00206552
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of intakes AZ00199598, AZ00202192, AZ00202650, AZ00202642
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was conducted following a complaint and report of physical abuse of a resident by her family member, involving a head-lock incident during the resident's discharge process to an assisted living facility.
Complaint Details
The complaint was substantiated. The family member was arrested for domestic violence assault after placing the resident in a head-lock. Staff and facility reports confirmed the abuse incident.
Findings
The facility failed to protect one resident from abuse by a family member who placed the resident in a choke hold. The incident was substantiated by staff interviews and facility documentation. Additionally, the facility failed to ensure proper infection prevention and control practices during incontinence care, specifically improper hand hygiene by staff.
Deficiencies (2)
Failed to protect a resident from physical abuse by a family member who placed the resident in a choke hold.
Failed to implement proper transmission-based precautions and hand hygiene during incontinence care, risking infection transmission.
Report Facts
Residents Affected: 1
Date of abuse incident: Mar 11, 2022
Date of observation: Oct 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) | Witnessed family putting resident in head-lock (staff #60) | |
| Environmental Services Director (EVS) | Intervened to remove family grip from resident (staff #41) | |
| Licensed Practical Nurse (LPN) | Performed pericare with improper hand hygiene (staff #91) | |
| Director of Nursing (DON) | Provided interview on facility policy and expectations (staff #3) |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was conducted following a complaint and report of physical abuse of a resident by her family member at the facility.
Complaint Details
The complaint investigation was substantiated. The family member was arrested for domestic violence assault after physically abusing the resident on March 11, 2022. Staff interviews and facility documentation confirmed the incident.
Findings
The facility substantiated an incident where a resident was physically abused by a family member who placed the resident in a choke hold. Additionally, the facility failed to ensure proper infection prevention practices during incontinence care, specifically improper hand hygiene by staff.
Deficiencies (2)
Failed to protect a resident from physical abuse by a family member resulting in a choke hold.
Failed to implement proper transmission-based precautions and hand hygiene during incontinence care.
Report Facts
Date of incident: Mar 11, 2022
Date of observation: Oct 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) | Witnessed family putting resident in head lock and confirmed incident in interview | |
| Environmental Services Director (EVS) | Intervened to remove family’s grip on resident and confirmed incident in interview | |
| Licensed Practical Nurse (LPN) | Observed performing pericare with improper hand hygiene | |
| Director of Nursing (DON) | Provided policy expectations and confirmed staff training requirements |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 4
Date: Oct 19, 2023
Visit Reason
Complaint survey citing deficiencies related to abuse, infection control, and policies.
Complaint Details
Investigation of multiple intakes including AZ00201796, AZ00195578, AZ00195723, AZ00195862, AZ00195918, AZ00197633, AZ00198821, AZ00199575, AZ00201331, AZ00201362
Findings
Complaint survey citing deficiencies related to abuse, infection control, and policies.
Deficiencies (4)
R9-10-403.C. Policies and procedures for physical health services and behavioral health services
§483.12 Freedom from Abuse, Neglect, and Exploitation
§483.80 Infection Control The facility must establish and maintain an infection prevention and control program
R9-10-410.B. An administrator shall ensure that: R9-10-410.B.3.a. Abuse
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of intake AZ00200588
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
Complaint survey with no deficiencies cited.
Complaint Details
Investigation of complaint AZ00198475
Findings
Complaint survey with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify responsible parties of resident falls and failure to implement fall prevention interventions for residents at risk of falls.
Complaint Details
The investigation was complaint-driven, focusing on notification failures and fall prevention practices. The deficiencies were substantiated based on clinical record reviews, staff interviews, and policy reviews.
Findings
The facility failed to notify the responsible party timely of a resident's fall with injury and failed to implement adequate interventions to prevent falls for another resident. Interviews with staff and review of clinical records and policies confirmed these deficiencies.
Deficiencies (2)
Failure to ensure that the responsible party was notified of a fall with injury for one resident (#186).
Failure to ensure intervention was implemented to prevent a fall for one resident (#29).
Report Facts
Sample size: 19
Fall risk score: 10
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #12 | Registered Nurse (RN) | Interviewed regarding notification of family or POA after resident fall |
| Staff #80 | Licensed Practical Nurse (LPN) | Interviewed about fall assessment and notification procedures |
| Director of Nursing (DON) | Director of Nursing | Interviewed about fall incident investigation and notification expectations |
| Staff #105 | Certified Nurse Assistant (CNA) | Involved in resident #29 fall incident and interviewed about the event |
| Staff #73 | Licensed Practical Nurse (LPN) | Interviewed about resident #29 fall and subsequent actions |
| Staff #50 | Certified Nurse Assistant (CNA) | Interviewed about staffing and assistance requirements for residents |
| Director of Rehabilitation (DOR) | Director of Rehabilitation | Interviewed about resident #29's functional status and assistance needs |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 5
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify responsible parties of resident falls, inadequate fall prevention interventions, insufficient registered nurse coverage, improper medication administration, and expired medication storage.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify family or POA of resident falls, inadequate fall prevention, insufficient RN coverage, improper medication administration, and expired medication storage.
Findings
The facility failed to timely notify family or POA of resident falls, did not implement adequate fall prevention interventions for at-risk residents, lacked consistent RN coverage for at least eight consecutive hours daily, administered pain medication outside prescribed parameters, and stored expired medications and supplies accessible for resident use.
Deficiencies (5)
Failed to notify responsible party of a fall with injury for one resident (#186).
Failed to implement intervention to prevent a fall for one resident (#29).
Failed to use services of a registered nurse for at least eight consecutive hours a day, seven days a week.
Failed to ensure one resident (#11) was free from unnecessary pain medications given outside ordered parameters.
Failed to ensure expired supplies and medications were not available for resident use.
Report Facts
Census: 85
Sample size: 19
Fall risk score: 10
RN coverage missing dates: 10
Medication administration outside parameters: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #12 | Registered Nurse | Interviewed regarding notification of family or POA of resident condition |
| Staff #80 | Licensed Practical Nurse | Interviewed regarding fall assessment and expired medication observation |
| Staff #105 | Certified Nurse Assistant | Involved in resident #29 fall incident |
| Staff #50 | Certified Nurse Assistant | Interviewed about resident assistance requirements |
| Staff #73 | Licensed Practical Nurse | Interviewed regarding fall incident and assessment |
| Staff #98 | Director of Rehabilitation | Interviewed regarding resident #29 functional status and assistance needs |
| Staff #32 | Director of Nursing | Interviewed regarding fall notification, RN coverage, and medication administration |
| Staff #110 | Licensed Practical Nurse | Interviewed regarding pain medication administration |
| Staff #111 | Staffing Coordinator | Interviewed regarding RN coverage |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify responsible parties of resident falls and failure to implement fall prevention interventions for residents at risk of falls.
Complaint Details
The investigation was complaint-driven, focusing on notification failures and fall prevention. The report indicates that the complaint was substantiated with findings of deficient practices related to notification and fall prevention.
Findings
The facility failed to notify the responsible party timely of a resident's fall with injury and failed to implement adequate interventions to prevent falls for another resident, resulting in avoidable accidents and potential harm.
Deficiencies (2)
Failure to ensure that the responsible party was notified of a fall with injury for one resident (#186).
Failure to ensure intervention was implemented to prevent a fall for one resident (#29).
Report Facts
Sample size: 19
Fall risk score: 10
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN/staff #12) | Interviewed regarding notification policy for resident falls | |
| Licensed Practical Nurse (LPN/staff #80) | Interviewed about fall assessment and notification procedures | |
| Director of Nursing (DON) | Interviewed about fall incident expectations and notification failures | |
| Certified Nurse Assistant (CNA/staff #105) | Involved in resident #29 fall incident and interviewed about the event | |
| Licensed Practical Nurse (LPN/staff #73) | Interviewed about assessment and notification after resident #29 fall | |
| Certified Nurse Assistant (CNA/staff #50) | Interviewed about staffing and assistance requirements for residents | |
| Director of Rehabilitation (DOR/staff #98) | Interviewed about resident #29's functional status and assistance needs |
Inspection Report
Census: 85
Deficiencies: 5
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, fall prevention, and medication storage at Haven of Saguaro Valley nursing home.
Findings
The facility was found deficient in multiple areas including failure to timely notify responsible parties of resident falls, inadequate fall prevention interventions, insufficient registered nurse coverage, administration of pain medication outside prescribed parameters, and storage of expired medications and supplies.
Deficiencies (5)
Failure to notify resident's family or Power of Attorney of a fall with injury in a timely manner for resident #186.
Failure to implement interventions to prevent falls for resident #29, resulting in avoidable accidents.
Failure to ensure registered nurse coverage for at least eight consecutive hours daily, seven days a week.
Failure to ensure resident #11 was free from unnecessary pain medications; administration of oxycodone outside ordered pain scale parameters.
Failure to ensure expired supplies and medications were not available for resident use.
Report Facts
Census: 85
Sample size: 19
Registered nurse coverage missing days: 10
Medication administration outside parameters: 4
Fall risk score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding fall notification, RN coverage, and medication administration | |
| Licensed Practical Nurse (LPN) staff #80 | Interviewed regarding fall assessment and expired medication observation | |
| Certified Nurse Assistant (CNA) staff #105 | Involved in resident #29 fall incident | |
| Director of Rehabilitation (DOR) staff #98 | Interviewed regarding resident #29 functional status and assistance needs | |
| Licensed Practical Nurse (LPN) staff #110 | Interviewed regarding pain medication administration |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 8
Date: Apr 13, 2023
Visit Reason
State compliance survey citing multiple deficiencies including notification failures, accident hazards, medication issues, and nursing services.
Complaint Details
Investigation of intakes AZ00185508, AZ00187353, AZ00188034, AZ00188867, AZ00188900, AZ00189158
Findings
State compliance survey citing multiple deficiencies including notification failures, accident hazards, medication issues, and nursing services.
Deficiencies (8)
§483.10(g)(14) Notification of Changes. Facility must notify responsible parties of changes
§483.25(d) Accidents. Facility must ensure resident environment is free of accident hazards
§483.35(b) Registered nurse services required
§483.45(d) Unnecessary Drugs-General. Resident's drug regimen must be free from unnecessary drugs
§483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals must be labeled properly
R9-10-412.B. Director of nursing must ensure timely notification and no unnecessary drug administration
R9-10-421.D. Medication storage policies and procedures
R9-10-425.A. Nursing care institution premises and equipment must be free from hazards
Inspection Report
Census: 86
Capacity: 112
Deficiencies: 2
Date: Apr 13, 2023
Visit Reason
Life Safety Code recertification survey found deficiencies related to corridor doors and exposed wiring.
Findings
Life Safety Code recertification survey found deficiencies related to corridor doors and exposed wiring.
Deficiencies (2)
Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke or fire
Utilities - Gas and Electric Equipment must comply with NFPA 54 and electrical wiring standards
Inspection Report
Routine
Deficiencies: 2
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards related to pressure ulcer prevention and treatment, as well as appropriate care to prevent urinary tract infections in residents.
Findings
The facility failed to provide appropriate pressure ulcer care and prevention, resulting in actual harm to a few residents, including inadequate wound assessments and incomplete documentation. Additionally, the facility failed to ensure proper care and timely provider notification for urinary tract infections in two residents, increasing risks of pain, infection, and rehospitalization.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including incomplete wound assessments and documentation.
Failure to provide appropriate care to prevent and treat urinary tract infections, including lack of timely provider notification and incomplete documentation.
Report Facts
Wound measurements: 8.5
Wound measurements: 2.5
Wound measurements: 2.2
Wound measurements: 0.7
Wound measurements: 6.5
Stage 3 pressure ulcer size: 6
Stage 3 pressure ulcer size: 10
Stage 3 pressure ulcer size: 9.5
Resident temperature: 102.3
Resident pulse: 100
Resident oxygen saturation: 87
UTI colony forming units: 100000
UTI colony forming units: 10000
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #70) | Interviewed regarding skin breakdown prevention and catheter care | |
| Licensed Practical Nurse (LPN/staff #90) | Interviewed regarding wound observation and UTI symptom monitoring | |
| Wound Nurse (staff #40) | Interviewed and observed wound care, described wound assessment procedures | |
| Director of Nursing (DON/staff #96) | Interviewed regarding wound care expectations and UTI management |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to pressure ulcer prevention and treatment, as well as appropriate care to prevent urinary tract infections in residents.
Findings
The facility failed to provide adequate care and services to prevent and treat pressure ulcers in one resident and urinary tract infections in two residents, increasing risks of pain, infection, and rehospitalization. Documentation and wound evaluations were incomplete, and provider notifications were delayed or absent.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in resident #12.
Failure to provide appropriate care to prevent and/or treat urinary tract infections in residents #7 and #13.
Report Facts
Wound measurements: 8.5
Wound measurements: 4.5
Wound measurements: 4
Wound measurements: 6
Wound measurements: 6
Wound measurements: 0.1
Wound measurements: 10
Wound measurements: 7
Wound measurements: 0.2
Wound measurements: 9.5
Wound measurements: 6.5
Wound measurements: 0.1
Resident score: 15
Temperature: 102.3
Antibiotic dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #70) | Interviewed regarding skin breakdown prevention and catheter care | |
| Licensed Practical Nurse (LPN/staff #90) | Interviewed regarding wound observation and UTI symptom notification | |
| Wound Nurse (staff #40) | Interviewed and observed providing wound care and measurements | |
| Director of Nursing (DON/staff #96) | Interviewed regarding wound care expectations and UTI management |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 112
Deficiencies: 3
Date: Mar 21, 2023
Visit Reason
Complaint investigation citing deficiencies related to skin integrity, incontinence care, and care planning.
Complaint Details
Investigation of complaint #AZ00192311
Findings
Complaint investigation citing deficiencies related to skin integrity, incontinence care, and care planning.
Deficiencies (3)
§483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers prevention and care
§483.25(e) Incontinence care and services
R9-10-414.B. Care plan must ensure nursing care institution services
Inspection Report
Routine
Deficiencies: 9
Date: Mar 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, notification procedures, care planning, respiratory care, pain management, staffing, medication safety, medical record accuracy, and staff training.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, inadequate notification of transfer/discharge rights, failure to implement care plans for assistive devices, lack of physician orders for oxygen administration, delayed and inconsistent pain management, missing nurse staffing postings, administration of medication outside ordered parameters without physician notification, inaccurate documentation of advance directives, and incomplete dementia training for some staff.
Deficiencies (9)
Failed to ensure call light was within reach of resident #50.
Failed to provide timely notification to resident #341 and representative of transfer/discharge rights and failed to send notice to Ombudsman.
Failed to implement care plan for resident #53 regarding providing a sippy type lid assistive device.
Failed to ensure residents #62 and #63 had physician orders for oxygen administration.
Failed to provide pain management consistent with standards for resident #241, including delayed administration of stronger pain medication and inadequate pain assessments.
Failed to retain all daily nurse staffing postings for a minimum of 18 months.
Failed to ensure resident #9's drug regimen was free from unnecessary drugs by administering blood pressure medication outside ordered parameters without physician notification.
Failed to accurately document resident #395's advance directives, resulting in conflicting code status information.
Failed to provide dementia training to 2 of 10 sampled staff (#24 and #15).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff affected: 2
Missing daily staffing postings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #77 | Restorative Nursing Assistant | Named in call light deficiency finding |
| Staff #109 | Named in call light deficiency finding | |
| Staff #22 | Director of Nursing | Named in call light, transfer notification, oxygen order, pain management, staffing, and advance directive findings |
| Staff #103 | Licensed Practical Nurse | Named in transfer notification and oxygen order findings |
| Staff #9 | Licensed Practical Nurse | Named in assistive device care plan deficiency |
| Staff #7 | Director of Rehabilitation | Named in assistive device care plan and dementia training findings |
| Staff #45 | Certified Nursing Assistant | Named in oxygen order deficiency |
| Staff #44 | Licensed Practical Nurse | Named in medication regimen deficiency |
| Staff #57 | Licensed Practical Nurse | Named in pain management deficiency |
| Staff #82 | Licensed Practical Nurse | Named in pain management deficiency |
| Staff #24 | Speech Therapist | Named in dementia training deficiency |
| Staff #15 | Certified Occupational Therapy Assistant | Named in dementia training deficiency |
| Staff #1 | Human Resources | Named in dementia training deficiency |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, advance directives, and staff training in a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, inadequate notification of transfer/discharge rights, failure to implement care plans for assistive devices, lack of physician orders for oxygen administration, delayed and inconsistent pain management, incomplete nurse staffing postings, administration of medications outside ordered parameters without physician notification, inaccurate documentation of advance directives, and incomplete dementia training for some staff.
Deficiencies (9)
Failure to ensure call light was within reach of resident #50.
Failure to provide timely written notification of transfer/discharge rights to resident #341 and representative.
Failure to implement care plan for resident #53 regarding provision of a sippy cup assistive device.
Failure to ensure physician orders for oxygen administration for residents #62 and #63.
Failure to provide timely and effective pain management for resident #241.
Failure to retain all daily nurse staffing postings for a minimum of 18 months.
Failure to ensure resident #9's blood pressure medication was held when systolic BP was below ordered parameters and failure to notify physician.
Failure to accurately document resident #395's advance directives in the medical record.
Failure to provide dementia training to two sampled staff (#24 and #15).
Report Facts
Sample size: 23
Deficiencies cited: 9
Blood pressure readings below medication parameters: 8
Missing daily staff postings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #77 | Restorative Nursing Assistant | Observed placing call light within reach of resident #50 |
| Staff #109 | Nursing Staff | Interviewed regarding call light use for resident #50 |
| Director of Nursing | Director of Nursing (DON) | Provided expectations on call light placement and reviewed multiple findings |
| Staff #103 | Licensed Practical Nurse (LPN) | Interviewed regarding transfer/discharge notification and oxygen orders |
| Staff #22 | Director of Nursing (DON) | Interviewed regarding transfer/discharge notification, oxygen orders, pain management, and advance directives |
| Staff #7 | Director of Rehabilitation | Interviewed regarding assistive device care plan and dementia training |
| Staff #9 | Licensed Practical Nurse (LPN) | Interviewed regarding assistive device use |
| Staff #45 | Certified Nursing Assistant (CNA) | Interviewed regarding oxygen use for resident #63 |
| Staff #44 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and oxygen orders |
| Staff #57 | Licensed Practical Nurse (LPN) | Documented pain management notes for resident #241 |
| Staff #82 | Licensed Practical Nurse (LPN) | Interviewed regarding pain medication administration for resident #241 |
| Staff #120 | Staff in Staffing and Central Supply | Interviewed regarding missing daily staff postings |
| Staff #1 | Human Resources | Interviewed regarding staff training records |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 25, 2019
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to provide appropriate behavioral health treatment and services to a resident with mental disorder and psychosocial adjustment difficulties, as well as concerns about food service safety practices.
Complaint Details
The complaint investigation focused on the facility's failure to provide appropriate behavioral health treatment and services to a resident (#295) with adjustment disorder and related behaviors, and concerns about food service safety practices that could place residents at risk for foodborne illnesses.
Findings
The facility failed to provide individualized behavioral health treatment and services for a resident with adjustment disorder, resulting in ongoing verbal outbursts and distress without adequate interventions. Additionally, the facility failed to serve food in accordance with professional food safety standards, as staff were observed handling food with bare hands, risking foodborne illness.
Deficiencies (2)
Failure to provide appropriate behavioral health treatment and services to a resident with mental disorder and psychosocial adjustment difficulty.
Failure to serve food in accordance with professional standards for food service safety, including staff handling food with bare hands.
Report Facts
Dates of behavioral symptoms: 17
Number of residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Manager | Social Services Manager (staff #3) | Spoke with resident about psychiatric services and yelling behavior; managed psychiatric services list. |
| Director of Nursing | Director of Nursing (DON, staff #22) | Spoke with resident about yelling behavior; provided information on psychiatric services availability and medication orders. |
| Certified Nursing Assistant | Certified Nursing Assistant (staff #61) | Observed interacting with resident during crying episodes and food service observation. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN, staff #5) | Interviewed regarding resident's behaviors and medication refusals. |
| Kitchen Manager | Kitchen Manager (staff #45) | Interviewed regarding food service safety practices. |
| Certified Nursing Assistant | Certified Nursing Assistant (staff #47) | Observed handling food with bare hands during meal service. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 25, 2019
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate behavioral health treatment and services to a resident with mental disorder and psychosocial adjustment difficulties, as well as concerns about food service safety practices.
Complaint Details
The complaint investigation focused on a resident (#295) with adjustment disorder exhibiting frequent yelling and disruptive behaviors. The resident declined psychotropic medication and outpatient psychiatric services. The facility lacked timely and adequate behavioral interventions. Food service safety concerns were also observed, including improper handling of food by staff.
Findings
The facility failed to provide individualized behavioral health treatment and services for a resident with adjustment disorder, resulting in ongoing verbal outbursts and distress without adequate interventions. Additionally, the facility failed to serve food in accordance with professional food safety standards, risking foodborne illness.
Deficiencies (2)
Failure to provide appropriate behavioral health treatment and services to a resident with mental disorder and psychosocial adjustment difficulty.
Failure to serve food in accordance with professional standards for food service safety, including staff using bare hands to handle food.
Report Facts
Dates of documented verbal symptoms: 13
Dates of documented frequent crying: 13
Dates of yelling or screaming: 13
Dates of behavioral symptoms directed at others: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Manager | Spoke with resident about psychiatric services and yelling behavior; managed psychiatrist patient list | |
| Director of Nursing (DON) | Spoke with resident about yelling behavior; confirmed in-house psychiatric services availability; involved in medication order and refusal documentation | |
| Certified Nursing Assistant (staff #61) | Observed resident crying daily and attempted to calm resident | |
| Licensed Practical Nurse (LPN, staff #5) | Interacted with resident daily; documented medication refusals | |
| Kitchen Manager (staff #45) | Interviewed regarding food handling practices and policy | |
| Certified Nursing Assistant (staff #47) | Observed handling food with bare hands during resident feeding |
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