Haven of Saguaro Valley

In the surveyor’s words

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

• Actual harm, isolatedF686Mar 21, 2023

  Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one resident (#12) received care and services to promote the prevention, healing, and prevent the development of additional pressure ulcers/injury consistent with professional standards of practice. The sample size was 3. The deficient practice increases the risk of pain, infection, and rehospitalization . Findings include: Resident #12 readmitted to the facility on [DATE] with diagnoses including COVID-19, type 2 diabetes mellitus and adult failure to thrive. The baseline risk for skin impairment care plan dated 02/17/23 related to bowel and bladder incontinence, weakness and a pressure ulcer present upon admission had a goal to have intact skin. […]

• Actual harm, isolatedF690Mar 21, 2023

  Based on clinical record review, staff interviews, and policy, the facility failed to ensure that 2 out of 3 residents reviewed (#7 and #13) received care and services to prevent and/or treat urinary tract infections. The deficient practice may increase the risks for pain, infection and rehospitalization . Findings include: -Resident #7 readmitted to the facility 07/06/22 with diagnoses including paroxysmal atrial fibrillation, benign prostatic hyperplasia with lower urinary tract symptoms and other obstructive and reflux uropathy. An indwelling catheter care plan dated 06/24/22 related to other obstructive and reflux uropathy had a goal to remain free from catheter-related trauma. […]

• No harm, potential for more than minimal, patternF727Apr 13, 2023

  Based on staff interviews and review of facility documentation and policy, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. The census was 66 and the sample was 17. The deficient practice could result in resident not provided with advanced care activities to meet their needs. Findings include: The Facility Assessment with completion dated of February 1, 2023 revealed tan average daily census range of 90-105. Staffing planning included one FT (full time) DON (director of nursing), wound nurse, admission nurse, unit manager; and, two FT MDS (minimum data set) nurses. […]

• No harm, potential for more than minimal, patternF656Mar 25, 2022

  Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to implement the care plan for one resident (#53) regarding providing an assistive device. The sample size was 23. The deficient practice could result in residents' needs not being met. Findings include: Resident #53 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised March 5, 2020 revealed the resident has an Activities of Daily Living (ADL) Self Care Performance Deficit related to weakness, [CONDITION(S)], incontinence, obesity, history of [CONDITION(S)], scoliosis, [CONDITION(S)], and a history of falls. The goal included the resident will improve their current level of function in eating. […]

• No harm, potential for more than minimal, patternF697Mar 25, 2022

  Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one sampled resident (#241) was provided pain management consistent with professional standards of practice, the person-centered care plan, and the resident's goals and preferences. The deficient practice could result in residents' pain not being managed. Findings include: Resident #241 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An alert progress note dated December 21, 2021 at 3:11 p.m. revealed the resident arrived at 1:24 p.m. via stretcher. […]