Haven of Show Low

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 16, 2025

  Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#18) was provided care and services, according to professional standards and physician orders, to prevent a new pressure ulcer and prevent worsening of existing pressure ulcers. The deficient practice could lead to physical harm of residents developing new or worsening wounds. -Findings Include: Resident #18 was initially admitted to the facility September 25, 2019, with diagnoses that included hyperlipidemia, chronic kidney disease, diastolic heart failure, neuromuscular dysfunction of bladder, ulcer of anus and rectum, and localized edema. […]

• Actual harm, isolatedF684Aug 19, 2024

  Based on clinical record review and staff interviews, the facility failed to ensure care and services related to wound was provided one resident (#57). The deficient practice resulted in the wound becoming necrotic and resident's transfer to the hospitalization . Findings include: Resident #57 was admitted to the facility on [DATE] with a diagnoses of Atrial Fibrillation, acute kidney failure, type II diabetes mellitus, systemic inflammatory response syndrome and bilateral lower extremity amputations. The admission note dated June 21, 2024 included the resident was admitted from a short-term general hospital, was confused as to situation and place and had bilateral lower extremity amputations. […]

• No harm, potential for more than minimal, patternF658Sep 27, 2024

  Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#56) received medical care treatments ordered by the physician. The deficient practice could result in residents not improving. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included enterocolitis due to Clostridium Difficile (Cdiff), urinary tract infection (UTI), neuromuscular dysfunction of the bladder, and Parkinson's Disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicated the resident was moderately cognitively impaired. It also included that the resident did not reject care during the look-back period. […]

• No harm, potential for more than minimal, patternF761Aug 8, 2024

  Based on observation, staff interview, and policy review, the facility failed to ensure that medications were dated when opened; and, failed to ensure expired medications were discarded and not readily available for resident use. The deficient practice could result in medication errors, reduced drug effectiveness and adverse reactions. The facility census was 48. Findings include: A medication observation was conducted on August 5, 2024 at 11:19 a.m. There was a white pill in a medicine cup on the bedside table of a resident #145 that was left unattended. The resident stated the pill was his phosphorus binder that was taken prior to lunch; and that, he self-administers this medication on a daily basis. […]

• No harm, potential for more than minimal, patternF812Aug 8, 2024

  Based on observations, staff interview, and review of policy and procedures, the facility failed to discard food/liquid items by their use-by-dates, failed to ensure that food items were appropriately refrigerated, and failed to ensure appropriate hand hygiene during food preparation and during the serving line. The census was 48, sample was 12. Findings include: An observation of the unit norishment refrigerator/freezer was conducted on [DATE] at 9:33 a.m. revealed an unlabeled container that contained a purple colored liquid substance had an expiration date of [DATE]. Another observation was conducted on [DATE] at 11:32 a.m. The cook (staff #5) placed a gloved hand into a salad bag removing the salad mix from the bag, then placing it on the plate. […]