Haven of Globe

In the surveyor’s words

From the most serious findings on record at Haven of Globe, in the surveyor’s own words.

• Actual harm, isolatedF686May 13, 2022

  Based on clinical record reviews, observations, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that 2 out of 3 sampled residents (#57 and #40) received care and services, consistent with professional standards of practice, to prevent, treat, and/or heal pressure ulcers. The deficient practice could result in residents developing pressure ulcers or worsening of pressure ulcers. Findings include: -Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A risk for pressure ulcer development care plan dated 03/25/15 related to [CONDITION(S)], incontinence and immobility had a goal for intact skin, free of redness and discoloration. […]

• Actual harm, isolatedF690May 13, 2022

  Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one sampled resident (#40) with an indwelling urinary catheter was provided care and services to prevent skin impairment. The deficient practice could result in residents with indwelling urinary catheters having skin breakdown issues. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan initiated on April 5, 2022 revealed the resident had an indwelling suprapubic catheter. The goal was that the resident would be/remain free from catheter-related trauma. […]

• No harm, potential for more than minimal, patternF600Jun 10, 2026

  Based on an observation, clinical record review, interviews, facility documentation and policies, and review of the State Agency (SA) database, the facility failed to protect the rights of 3 out of 18 sampled residents (#92, #93, #8) to be free from physical and verbal abuse by another resident. The deficient practice could result in further resident abuse.Findings included:-Regarding Resident #92 (alleged victim) and Resident #12 (alleged perpetrator) -Resident #92 was admitted on [DATE] with diagnosis that included Type 2 Diabetes Mellitus, dementia, and blindness of one eye.Review of clinical records dated December 21, 2022 through December 29, 2022 revealed that the resident had to be redirected back to her room several times, and wandered multiple times throughout residents' rooms and… […]

• No harm, potential for more than minimal, patternF725Jun 10, 2026

  Based on review of the facility assessment, facility documentation, interviews, and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving the appropriate care to maintain safety, and the highest practicable physical, mental, and psychological well-being as determined by resident assessments and individual plans of care.Findings include:The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2025, and the first quarter of 2026. […]

• No harm, potential for more than minimal, patternF761Jun 10, 2026

  Based on observations, staff interviews, and policy review, the facility failed to ensure that drugs and biologicals were stored, secure, and inaccessible to unauthorized staff and residents in accordance with facility policy, state, and federal laws for four of eighteen sampled residents (#5, #22, #69, #89). The universe was seventy-one. The deficient practice could lead to medications being incorrectly administered or accidentally ingested by a resident. Findings Include: -Regarding Resident #5 Resident #5 was admitted on [DATE] with diagnosis including bipolar disorder, current episode-depressed, dementia-unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, psychosis not due to a substance or known psychological condition,… […]