Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Show Low during CMS and state inspections, most recent first.
A resident with paraplegia and multiple pressure ulcers did not receive wound care and assessments as ordered, including missed treatments, incomplete documentation, and lack of physician notification for a new facility-acquired scrotal ulcer. Nursing staff and leadership confirmed gaps in care and documentation, and the resident was later hospitalized for sepsis related to a sacral wound.
A resident with cognitive impairment and a history of wandering ingested bleach after confusing a bleach wipe container for a water cup, as cleaning wipe containers were left accessible in the room. Staff interviews and observations confirmed that hazardous chemicals were not consistently secured, and there was no specific facility policy for chemical storage, contributing to the incident.
A resident with multiple diagnoses did not receive physician-ordered treatments, including catheter care, Nystatin powder application, and oxygen saturation checks. Interviews with an LPN and the DON confirmed the missed treatments and the associated risks, highlighting a deficiency in documentation and adherence to physician orders.
A resident with multiple medical conditions and a Foley catheter experienced inadequate wound care management, resulting in a necrotic wound and hospitalization. Despite complaints and a physician's order, there was no documented care plan or timely referral to a wound clinic. Staff interviews revealed systemic issues, including the absence of a wound care nurse and inadequate documentation practices.
The facility failed to ensure proper labeling and storage of medications, with several opened bottles found without open dates and expired medications not discarded. A resident's phosphorus binder was left unattended, and a bag of IV Ceftriaxone was left on a medication cart. Staff interviews revealed unfamiliarity with policies, and the DON confirmed the need for proper dating and discarding of medications.
The facility failed to follow proper food safety and hand hygiene practices. Observations revealed expired food items in the refrigerator and improper glove use during food preparation and serving. Staff did not change gloves or wash hands between handling different food items, leading to potential cross-contamination. Interviews with management confirmed these practices did not meet facility expectations.
A resident with moderate cognitive impairment was found to be self-administering medication without a documented assessment for safety, contrary to facility policy. The resident's medication was left unattended at the bedside, which staff interviews confirmed was against policy. The DON stated there was no self-administration determination in the resident's clinical record.
Two residents were not given advance written notice of room changes, violating their rights. Despite having intact cognition, they were moved without proper notification, leading to dissatisfaction and distress. The facility's policy requires advance written notice, which was not adhered to, as confirmed by the administrator and DON.
A facility failed to complete a required PASRR Level I screening for a resident with multiple mental health diagnoses who stayed longer than 30 days. The initial screening was done, but no follow-up was conducted despite new diagnoses and an extended stay. Staff interviews confirmed the oversight, which did not meet facility expectations.
A resident with severe cognitive impairment and their representative were not involved in care planning despite documentation indicating their participation. Interviews revealed that neither the resident nor the representative were aware of or attended care conferences. Facility staff admitted to documentation errors, highlighting a failure to ensure proper involvement in care decisions.
A resident with cognitive impairments and safety awareness issues was observed smoking without supervision, despite the care plan requiring it. Staff interviews revealed a lack of adherence to the facility's smoking policy, as the resident was allowed to keep smoking materials in her room and smoke unsupervised. The facility's acting DON and MDS Coordinator confirmed the need for supervision, which was not implemented, leading to the deficiency.
A resident with a PICC line for antibiotic therapy due to a knee infection did not have their dressing changed as ordered by the physician. Despite documentation indicating site checks were completed, observations revealed the dressing was soiled and lacked proper labeling. Interviews with an LPN and the DON confirmed the dressing needed immediate replacement, highlighting a failure to adhere to the facility's policy.
A resident with hypotension and other conditions received Midodrine hydrochloride outside of physician-ordered parameters, as documented in the MAR for June and July. The facility's LPN and DON confirmed the medication was given despite the resident's SBP exceeding the specified limit, contrary to the facility's policy requiring adherence to physician orders and pre-administration assessments.
A resident with a history of diabetes, traumatic brain injury, and dementia did not have follow-up dental appointments scheduled after a consultation recommended further extractions. Despite documentation and staff acknowledgment of the need, the facility failed to ensure the appointments were made, as confirmed by interviews with the RN, transportation manager, and DON. This oversight did not meet facility standards and could risk the resident's health.
The facility failed to prevent elopement for two residents, one with dementia and another with encephalopathy, due to inadequate supervision and lack of alarms on certain exits. Additionally, a resident sustained a skin tear during wheelchair transport due to improper safety measures. These incidents highlight deficiencies in supervision and safety protocols.
An altercation between two residents with severe cognitive impairments occurred when one resident attempted to use a shared bathroom, resulting in a skin tear. The facility failed to document the incident promptly and did not check for potential causes of the injury. The investigation was delayed, and communication barriers were not addressed, highlighting deficiencies in resident safety and documentation.
A facility failed to report and investigate an abuse allegation within the required timeframe. A CNA documented a resident's claim of being overpowered and hit by staff, but the LPN did not report it to the Administrator or state agency. The Administrator discovered the issue during another investigation, noting the delay in reporting. Staff interviews confirmed awareness of the reporting protocol, which was not followed, risking potential abuse.
A facility failed to investigate and report an abuse allegation timely when a resident reported being overpowered and hit by staff. A CNA documented the claim but did not report it to the Administrator as required, and the alleged perpetrator, an LPN, was not suspended during the investigation. The Administrator discovered the allegation days later, delaying the report to the state agency and the five-day investigation submission. Interviews revealed communication lapses among staff, and the facility's abuse policy was not followed.
A resident with a UTI did not receive the prescribed antibiotic, Cefpodoxime Proxetil, due to unavailability from March 27 to March 30. Despite staff awareness and facility policies requiring medication administration, the antibiotic was not provided, leading to a deficiency in care.
The facility failed to meet professional standards during a call light system outage, falsely documenting visual checks for five residents. Despite using hand-held bells and implementing 15-minute Fire Watch checks, staff did not enter all required rooms, and documentation inaccurately indicated that visual checks were performed.
Failure to Provide Pressure Ulcer Care and Prevent New Ulcers
Penalty
Summary
A resident with multiple comorbidities, including paraplegia, chronic kidney disease, and a history of pressure ulcers, was not provided with care and services in accordance with professional standards and physician orders to prevent new pressure ulcers and the worsening of existing ones. The resident was dependent on staff for bed mobility and had a care plan identifying the risk for skin impairment, with interventions for weekly wound monitoring, measurement, and physician notification of changes. However, there was no evidence that the care plan was updated to address a newly developed, facility-acquired pressure ulcer on the scrotum, nor was there documentation of physician notification or treatment orders for this new wound. There were significant lapses in wound care management, including a lack of wound care orders or treatment for the left ischium wound for nearly two months, and missed or incomplete documentation of weekly wound assessments, measurements, and wound descriptors for several pressure ulcers. The clinical record showed gaps in weekly wound assessments, with no evidence of assessments or measurements between certain dates, and missing documentation regarding the presence of tunneling in wounds. Additionally, wound care treatments for the right ischium and sacral wounds were not completed as ordered on multiple occasions, with no documentation of resident refusal or coordination of alternative care times as outlined in the care plan. Interviews with nursing staff and facility leadership confirmed awareness of the missed wound care treatments and assessments, as well as the lack of documentation and physician notification for the new scrotal pressure ulcer. Facility policies required prompt notification of changes in resident condition, systematic and comprehensive assessments, and completion of physician-ordered treatments, but these were not followed. The resident was later transferred to the hospital and treated for sepsis secondary to a sacral wound, with wound cultures positive for infection.
Failure to Prevent Resident Access to Hazardous Chemicals Resulting in Bleach Ingestion
Penalty
Summary
A resident with a history of Parkinson's disease, anxiety disorder, hypertension, obesity, and liver abscess was admitted to the facility and exhibited signs of cognitive impairment, including wandering, attempts to leave the facility, and confusion regarding orientation. Despite these behaviors and documentation of impaired cognition, there was no care plan addressing cognitive impairment until more than two years after admission. The resident was known to wander into other residents' rooms and had difficulty with redirection, sometimes becoming combative with staff. On one occasion, the resident ingested bleach after filling a container that previously held bleach wipes with water and drinking from it, mistaking it for his water cup. The incident was discovered after the resident's roommate reported the behavior, and the resident himself indicated confusion between the bleach container and his water cup. The bleach wipe container was found accessible in the resident's room, and staff interviews confirmed that such containers should not be left within reach of residents, especially those with cognitive impairment. Further review revealed that the facility did not have a specific policy for chemical storage, relying instead on a general safety and supervision policy. Observations confirmed that cleaning wipe containers were accessible in resident rooms, and staff acknowledged that hazardous chemicals should be stored securely and not left in areas accessible to residents. The facility's policy emphasized the importance of identifying and mitigating accident hazards, but in practice, hazardous materials were not consistently secured, leading to the resident's accidental ingestion of bleach.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure that a resident received medical care treatments as ordered by the physician, which could result in residents not improving. The resident was admitted with diagnoses including enterocolitis due to Clostridium Difficile, urinary tract infection, neuromuscular dysfunction of the bladder, and Parkinson's Disease. The care plans included interventions for infections, enhanced barrier precautions, risk for skin impairment, and oxygen therapy. However, the Treatment Administration Record (TAR) revealed that several treatments were not administered as ordered, including catheter care, Nystatin powder application, and oxygen saturation checks. Interviews with staff revealed that the licensed practical nurse (LPN) and the Director of Nursing (DON) acknowledged the missed treatments and the associated risks. The LPN stated that treatments should be documented in the TAR, and if not documented, it indicates the treatment was not done. The DON confirmed that the catheter was not cleaned multiple times, increasing the risk of infection, and that the Nystatin powder was not applied as ordered, which could lead to the spread of infection. Both staff members emphasized the importance of documentation and adherence to physician orders. The facility's policy on administering medications and treatments requires that medications be administered safely, timely, and as prescribed, with documentation in the Medication Administration Record (MAR) or TAR. The failure to document and administer treatments as ordered represents a deficiency in meeting professional standards of quality care, as outlined in the facility's policies and procedures.
Failure in Wound Care Management Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate care and services related to wound management for a resident, leading to a necrotic wound and subsequent hospitalization. The resident, who had multiple medical conditions including atrial fibrillation, acute kidney failure, type II diabetes mellitus, and bilateral lower extremity amputations, was admitted with a Foley catheter. Despite complaints of discomfort and a physician's order to monitor urination and potentially replace the catheter, there was no documented care plan or interventions related to the catheter use. The resident's clinical records showed a lack of consistent documentation and follow-up on the condition of the resident's penis, which developed slough and inflammation. Despite the presence of a Foley catheter and recommendations for wound clinic referral, there was no evidence of timely action or proper catheter care. The resident's condition worsened, with significant necrosis noted by the wound clinic, which led to an emergency room referral. Interviews with staff revealed systemic issues, including the absence of a wound care nurse and inadequate documentation practices. The Director of Nursing acknowledged the problem, noting the delay in referring the resident to the wound clinic and the lack of individualized assessment notes. A CNA reported notifying the administration about the resident's condition, but the issue persisted, with some staff uncomfortable performing necessary care procedures.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey. On one occasion, a white pill was found unattended on a resident's bedside table, which the resident identified as a phosphorus binder that he self-administers daily. Additionally, during an inspection of medication carts, several opened bottles of medications, including Vitamin C, Vitamin B12, and aspirin, were found without open dates. The aspirin bottle was also expired. Staff interviews revealed a lack of familiarity with the facility's policy on dating opened medication bottles and checking for expired medications. Further observations revealed a bag of IV Ceftriaxone left unattended on a medication cart, with the LPN admitting to leaving IV medications unattended on several occasions. Additional opened medication bottles without open dates and expired medications were found on another medication cart. In the medication storage room, expired bottles of Nutricia Pro-Stat and an opened bottle of 8-Hour Arthritis Pain Relief without an open date were discovered. The Director of Nursing confirmed that medications should be dated upon opening and expired medications should be discarded immediately, but there was uncertainty about the 28-day time limit policy. The facility's policies on medication labeling and storage, as well as discarding medications, were reviewed, highlighting the deficiencies in practice.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, as observed during a survey. An unlabeled container with a purple liquid, identified as grape Kool-Aid, was found in the unit nourishment refrigerator/freezer with an expired date. The kitchen manager acknowledged that the container should have been removed, recognizing the risk of using expired food items. Additionally, during food preparation, a cook was observed using the same pair of gloves to handle various food items and touch personal items, such as a marker and refrigerator door, without changing gloves or washing hands. This included handling salad mix, boiled eggs, tomatoes, and cottage cheese, all without proper hand hygiene. Further observations during breakfast service revealed that a serving line cook removed gloves, adjusted clean stacks of plates and plate covers with bare hands, and then donned new gloves without washing hands. The cook then proceeded to handle food items, such as bananas, and served them without changing gloves. Interviews with the kitchen and dietary managers confirmed that these practices did not meet the facility's expectations for hand hygiene and food safety. The facility's policies on food storage, date marking, and general food preparation emphasize the importance of proper hand hygiene and the use of gloves to prevent cross-contamination, which were not followed in these instances.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safety of self-administering medication, which is a requirement for allowing residents to self-administer drugs. Resident #145, who was admitted with multiple diagnoses including clostridium difficile, enterocolitis, end-stage renal disease (ESRD), ankylosing spondylitis, and atherosclerotic heart disease, was found to have a moderate cognitive impairment with a BIMS score of 8. Despite this, there was no evidence in the clinical record that an assessment for self-administration was conducted or that it was deemed clinically appropriate for the resident to self-administer medication. During an observation, a white pill was found unattended on the bedside table of Resident #145, which the resident identified as his phosphorus binder taken before meals. The resident reported that he self-administers this medication daily, as allowed by the nursing staff. Interviews with nursing staff revealed that facility policy requires nurses to remain at the bedside until medications are taken and prohibits leaving medications unattended. The Director of Nursing confirmed that there was no self-administration determination in the clinical record for the resident, and the facility policy mandates that any unauthorized medications found at the bedside should be collected and reported.
Failure to Provide Advance Written Notice for Room Changes
Penalty
Summary
The facility failed to provide advance written notice to two residents regarding room changes, which is a violation of resident rights. Resident #24 experienced multiple room changes without proper notification. The clinical records lacked evidence of advance notice for room changes on several occasions, including June 22, 2023, December 4, 2023, February 9, 2024, and August 1, 2024. Despite having intact cognition, as indicated by a BIMS score of 15, Resident #24 did not recall being informed or signing any room change notices. The facility's documentation was incomplete, with missing resident signatures and reasons for room changes not adequately explained. Similarly, Resident #37, who also had a BIMS score of 15 indicating cognitive intactness, was not given advance written notice of a room change on August 1, 2024. The resident expressed dissatisfaction and distress over the room change, stating that they were informed verbally and moved on the same day without prior written notice. Interviews with the facility's administrator and DON confirmed that the required written notices were not provided to the residents, and the facility's policy mandates advance written notice for room changes, including the reasons for such changes.
Failure to Complete Required PASRR Screening
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) Level I screening was completed as required for a resident who was admitted with multiple mental health diagnoses, including major depressive disorder, bipolar disorder, post-traumatic stress disorder, and anxiety disorder. The initial PASRR Level I screening was conducted on November 8, 2022, and indicated that the resident's admission met the criteria for 30-day convalescent care. However, the resident remained in the facility for longer than 30 days, and new diagnoses were documented, including post-traumatic stress disorder and bipolar disorder with psychotic features. Despite these changes and the extended stay, there was no evidence of a subsequent PASRR Level I screening being completed after the initial assessment. Interviews with facility staff, including a social worker and the Director of Nursing (DON), confirmed that the last PASRR Level I screening was conducted on November 8, 2022, and acknowledged that another screening should have been completed after the resident's stay exceeded 30 days. The facility's policy requires a new PASRR Level I screening to be completed within 40 calendar days if the resident's stay extends beyond the initial 30-day convalescent period. The DON stated that the lack of a follow-up PASRR screening did not meet facility expectations and could have resulted in the resident not receiving appropriate specialized services for their diagnoses.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their representative were involved in the development of the care plan and in making decisions about the resident's care. The resident, who was admitted with chronic kidney disease, adult failure to thrive, tremor, chronic pain, depression, and mobility issues, had a severe cognitive impairment as indicated by a BIMS score of 6. Despite documentation suggesting that the resident and their representative attended care plan conferences, interviews revealed that they were not aware of or involved in these meetings. The resident and their representative expressed concerns about not being informed or involved in care planning. They reported that no staff member had met with them to discuss the care plan, and the representative had unsuccessfully attempted to contact the resident relations manager multiple times. The resident stated that they were unaware of any care conference meetings and had not participated in discussions about their care. The representative also denied attending any care conferences. Interviews with facility staff, including the Director of Nursing and the resident relations manager, revealed discrepancies in the documentation of care conferences. The resident relations manager admitted to an error in the documentation and stated that the care conference was held in the office with the activities director, with the representative attending via telephone. However, the Director of Nursing indicated that care conferences should be documented in the clinical record, contradicting the resident relations manager's understanding.
Inadequate Supervision of Resident Smoking
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with impaired safety awareness who wished to smoke. The resident, who had a history of cerebral infarction, monoplegia, aphasia, and cognitive impairments, was assessed as needing supervision while smoking. Despite this, the resident was observed with a lighter and cigarettes in her room and was seen smoking without supervision in the designated smoking area. Observations revealed that the resident was not wearing a smoking apron and was not supervised while smoking, contrary to the care plan and smoking assessment requirements. Interviews with staff indicated a lack of awareness and adherence to the facility's smoking policy. The CNA and nurse were unaware of the resident's need for supervision and the requirement to store smoking materials at the front desk. The facility's acting DON and MDS Coordinator confirmed that the resident's care plan and smoking assessment indicated the need for supervision, but these were not implemented. The facility's policy required direct supervision for residents needing monitoring while smoking, which was not followed, leading to the deficiency.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that the PICC line dressing for a resident was changed as ordered by the physician, which could result in complications such as infection. The resident, who was admitted with diagnoses including left knee staphylococcal arthritis and immunodeficiency, had a physician order for PICC line dressing changes every 7 days and as needed using sterile technique. However, during an observation, it was found that the PICC line dressing was not initialed, dated, or timed, and appeared dirty, indicating it had not been changed as required. The resident, who was cognitively intact, reported that the dressing was hardly changed and had not been changed that week, despite becoming dirtier each day. The resident was unaware of the required frequency for dressing changes but noted that the nurses continued to use the PICC line. This suggests a lack of adherence to the facility's policy and physician orders regarding PICC line care. Interviews with staff, including an LPN and the DON, revealed that the facility's policy required PICC line dressings to be changed at least once a week or if soiled, and the site to be checked every shift for signs of infection. Despite documentation indicating that site checks were completed, both the LPN and DON confirmed that the dressing was soiled and needed immediate replacement. They also acknowledged the absence of documentation indicating when the dressing was last changed, which was not in accordance with the facility's policy.
Failure to Administer Blood Pressure Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were administered according to physician-ordered parameters for a resident diagnosed with hypotension, major depressive disorder, bipolar disorder, and post-traumatic stress disorder. The resident's care plan included interventions to obtain blood pressure readings as ordered and under consistent conditions. A physician order specified that Midodrine hydrochloride should be held if the systolic blood pressure (SBP) was greater than 130. However, the Medication Administration Record (MAR) for June and July 2024 showed that Midodrine was administered on several occasions when the resident's SBP exceeded the ordered parameters, specifically on June 6, June 7, June 30, and July 3, 2024. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the medication was administered outside of the physician's parameters, which did not align with the facility's expectations or policy. The LPN acknowledged that the medication administration did not follow the physician's orders, and the DON stated that the provider should have been notified if the medication was administered outside the ordered parameters. The facility's policy on administering oral medications required verification of a physician's order and pre-administration assessments, which were not adhered to in this case.
Failure to Schedule Follow-Up Dental Appointments
Penalty
Summary
The facility failed to ensure that recommended follow-up dental appointments were scheduled for a resident, leading to a deficiency in providing necessary dental care. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, a history of traumatic brain injury, and unspecified dementia, had oral health problems documented in their care plan. A dental consultation on August 16, 2023, resulted in the extraction of three teeth and a recommendation for further extractions. Despite this recommendation being noted by a registered nurse, there was no evidence that a follow-up appointment was scheduled. Interviews with facility staff, including a registered nurse, the transportation manager, and the Director of Nursing, revealed that the process for scheduling follow-up appointments was not followed. The transportation manager confirmed that no follow-up dental appointments were scheduled after the initial consultation. The facility's policy indicated that nursing services should notify social services of a resident's need for dental services, but this process was not completed, resulting in a failure to meet facility standards and potentially putting the resident at risk for infection.
Inadequate Supervision and Safety Measures Lead to Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision and prevent elopement for two residents, leading to multiple incidents of elopement. One resident, diagnosed with dementia and severe cognitive impairment, was identified as a flight risk. Despite wearing a Wanderguard, the resident managed to elope multiple times, including an incident where the resident was found outside the facility near a Home Depot. The facility's lack of sensors on certain doors contributed to the resident's ability to leave the premises undetected. Another resident with a history of encephalopathy and alcohol dependence also eloped from the facility. This resident was observed exiting through a window and was later found by police at a nearby establishment. The facility's failure to have alarms on windows and inadequate monitoring of residents on isolation contributed to this incident. The resident's care plan included interventions such as hourly checks and distraction with activities, but these measures were insufficient to prevent the elopement. Additionally, the facility failed to prevent an accident involving a resident who sustained a skin tear while being transported in a wheelchair by a physical therapist. The therapist did not ensure the resident's arms were safely positioned within the wheelchair, resulting in the resident's arm making contact with a doorframe. This incident highlights a lack of adherence to safety protocols during resident transport, leading to injury.
Resident Altercation and Inadequate Documentation
Penalty
Summary
The facility failed to prevent an altercation between two residents, resulting in a deficiency related to resident safety and protection from abuse. Resident #14, who has severe cognitive impairment due to Alzheimer's disease and unspecified dementia, was involved in an incident with Resident #33, who also has similar cognitive impairments and communication barriers. The altercation occurred when Resident #33 attempted to use the shared bathroom while Resident #14 was already inside, leading to Resident #14 sustaining a skin tear on his right hand. The facility's documentation and staff interviews revealed that there was no immediate documentation of the incident in the progress notes, and the investigation into the altercation was delayed. The residents were not interviewed until three days after the incident, and by that time, they could not recall the details. Additionally, there was no documentation indicating that staff checked Resident #33's fingernails for sharpness, which could have caused the skin tear. The facility's response included moving Resident #33 to another part of the facility, but the initial handling of the situation lacked thoroughness and timely documentation. The facility's policy on abuse prevention acknowledges the challenges of caring for residents with dementia and other mental illnesses, yet the incident highlights a failure to adequately protect residents from harm. The lack of an interpreter for Resident #33, whose first language is not English, further complicated the investigation and communication. The deficiency report underscores the need for improved measures to prevent resident-to-resident altercations and ensure timely and comprehensive documentation of such incidents.
Failure to Timely Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse and complete a 5-day written investigation regarding a resident in the required timeframe. A certified nursing assistant (CNA) documented that a resident expressed feeling overpowered and hit by staff, which was reported to a licensed practical nurse (LPN). However, the LPN instructed the CNA to document it in a progress note and did not report the allegation to the Administrator or state agency as required. The resident was cognitively intact, as indicated by a BIMS score of 15, and had diagnoses including urinary tract infection, obesity, chronic kidney disease, and muscle weakness. The Administrator discovered the allegation while reviewing progress notes for another investigation, realizing the report was not made within the required two-hour timeframe. Interviews with staff revealed that both the CNA and the LPN were aware of the reporting protocol but failed to follow it. The facility's policy mandates immediate notification of the Executive Director and state survey agency, with an investigation to be completed within five working days. The delay in reporting and investigation could result in residents being abused.
Failure to Investigate and Report Abuse Allegation Timely
Penalty
Summary
The facility failed to conduct a thorough investigation into an abuse allegation involving a resident who reported being overpowered and hit by staff. The incident was initially reported by a CNA who documented the resident's claim in a progress note. However, the CNA did not follow the facility's policy of reporting the allegation to the Administrator within two hours, and the alleged perpetrator, an LPN, was not immediately suspended pending investigation. The Administrator only became aware of the allegation several days later while reviewing progress notes, leading to a delay in reporting the incident to the state agency and in submitting the required five-day investigation. Interviews conducted during the investigation revealed inconsistencies and a lack of communication among staff. The resident, who was cognitively intact, reported that the LPN squeezed her leg, but the LPN denied the allegation and claimed the resident frequently made false accusations. The CNA stated she reported the incident to the LPN, who instructed her to document it but did not take further action. Additionally, a physical therapist was informed by the resident of issues with the LPN but did not report this to a supervisor. The facility's policy on abuse requires immediate reporting and investigation of suspected abuse, with the alleged perpetrator being suspended during the investigation. However, these procedures were not followed, resulting in a delayed response to the abuse allegation. The Administrator acknowledged the failure to report the incident in a timely manner and the lack of immediate action to protect the resident from potential further abuse.
Failure to Administer Prescribed Antibiotic for UTI
Penalty
Summary
The facility failed to administer medication as prescribed for a resident with a urinary tract infection (UTI). The resident was admitted with diagnoses including UTI, obesity, chronic kidney disease, and muscle weakness. An order was placed for Cefpodoxime Proxetil, an antibiotic, to be administered twice daily for seven days. However, progress notes from March 27 to March 30 revealed that the medication was not available and remained on order, resulting in the resident not receiving the prescribed treatment. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed that the medication was not administered as prescribed. The staff acknowledged that the lack of medication could lead to worsening of the UTI and potential complications. The facility's policy required compliance with professional standards, but the failure to ensure the availability and administration of the prescribed antibiotic led to a deficiency in care for the resident.
Failure to Ensure Professional Standards During Call Light System Outage
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a period when the call light system was inoperable. Staff falsely documented that visual checks were conducted for five residents. The call light system had been down for almost two weeks, and residents were provided with hand-held bells as an alternative. Despite the implementation of 15-minute Fire Watch resident checks, observations revealed that staff did not enter certain resident rooms as required, and documentation inaccurately indicated that visual checks were performed. Interviews with staff, including a CNA, the Administrator, an RN, and the VP of Clinical Operations, confirmed the inoperability of the call light system and the use of hand-held bells. The RN and VP of Clinical Operations stated that the 15-minute checks should include visual confirmation of each resident's status. However, observations on two separate occasions showed that staff did not enter all rooms, and the Fire Watch checklists were inaccurately completed, indicating that visual checks were performed when they were not.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Show Low
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haven Of Lakeside | 0.1 mi | — | 21 | 0 |
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