Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Globe during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple chronic conditions was involved in a transfer when staff observed her stiffening and slipping from her wheelchair. During the assist, an LPN was reported to have hit, smacked, or jabbed the resident’s leg while telling her to relax and bend her knees. The resident later said the nurse hit her leg, a roommate heard yelling, and written statements described the resident as crying and reporting that she had been struck during care.
Abuse Allegation Not Thoroughly Investigated: A resident with moderate cognitive impairment and multiple medical conditions was involved in a transfer incident in which staff described her legs as rigid and locked. Witnesses and the resident reported that an LPN hit or smacked the resident’s leg while telling her to relax and bend her knees, and the resident became tearful and said she had been hit. The facility’s abuse investigation was inconsistent and incomplete, with omitted written witness statements and a conclusion that the allegation was unsubstantiated despite accounts describing physical contact.
A resident with multiple chronic conditions and moderate cognitive impairment was involved in an incident during a transfer when an LPN tapped or hit her leg while staff tried to reposition her. The resident’s family later reported that the nurse had struck her legs, and staff interviews confirmed the allegation was not reported immediately as required. The facility’s abuse policy required reporting within two hours, but the allegation was not escalated until the next morning.
Incomplete Investigation of Alleged Staff-to-Resident Abuse: A resident with moderate cognitive impairment and multiple medical conditions was involved in an alleged abuse incident during a transfer when staff observed her rigid and slipping from her wheelchair. Accounts differed, but witness statements and the resident’s report described an LPN hitting or smacking the resident’s legs while telling her to relax, and bruising was documented on the knees. The facility’s investigation was not thorough because it left out relevant written witness statements and still concluded the allegation was unsubstantiated.
A resident with dementia and wandering entered another resident’s space repeatedly, and a physical altercation occurred when the other resident pulled the first resident’s hair; staff later confirmed this was physical abuse, but the perpetrator’s care plan was not updated. The facility also failed to document or report an allegation involving a resident’s son using foul language and acting aggressively toward residents and staff, despite multiple witness statements and staff acknowledging the behavior met the definition of abuse.
Failure to timely report abuse investigation results: A CNA heard a scream and found one resident had pulled another resident’s hair after the other resident repeatedly entered the room. The residents were separated, no visible injuries were noted, and the provider, DON, case manager, families, and police were notified. However, the facility could not provide evidence that the completed investigation findings were submitted to the State Survey Agency within the required 5-working-day timeframe, and the State Agency tracking system showed no record of the submission.
Failure to Thoroughly Investigate Alleged Abuse: Staff found two residents involved in a hair-pulling incident after one resident was heard screaming and the other was found outside a room. One resident had dementia, wandering, and impaired decision making; the other had dementia, schizophrenia, hallucinations, and a history of aggression and wandering. Although the incident was reported and statements were taken, survey review found no evidence that the abuse allegation was thoroughly investigated or that the completed investigation was submitted to the State Agency within the required timeframe.
Insufficient nursing staffing and weekend coverage were identified after PBJ data showed repeated low weekend staffing and daily schedules showed RN/LPN and CNA assignments that exceeded the facility assessment. The facility was licensed for 104 residents with an average census of 78 to 85, yet multiple shifts had 35 to 39 residents per RN/LPN and 18 to 19 residents per CNA, with some shifts lacking a [NAME]. Staff interviews described missed tasks, skipped breaks, and staying past shifts, while the Staffing Coordinator said staffing was done "in my head" and did not know the facility assessment.
Medications were left unsecured in resident rooms for multiple residents without orders, assessments, or care plans authorizing self-administration. An LPN, CMA, and DON all confirmed that topicals and oral meds such as Nystatin, antifungal powder, Tums, and other tablets should not be left at bedside unless the resident had been evaluated and approved to self-administer, and the record showed no such authorization for the affected residents.
A resident with DM, HTN, and ESRD on HD had physician orders for insulin glargine to be held if BG was below 110 and isosorbide mononitrate ER to be held if systolic BP was below 110. MAR review showed multiple administrations of both medications despite readings below the ordered hold parameters. An RN and the DON both confirmed the orders were not followed.
Improper Foley Catheter Positioning and Care: Two residents with indwelling catheters were observed with catheter bags touching the floor, including one bag dragged and run over during wheelchair transport. Staff interviews confirmed the bags should have been secured below the bladder and off the floor, and records showed ordered catheter care was provided but no replacement of the bag or tubing was documented during the review period.
Multiple residents with severe cognitive impairment were involved in physical altercations with each other, resulting in minor injuries and visible marks. Staff intervened in each case, but the incidents were substantiated by facility investigations, indicating a failure to prevent resident-to-resident abuse.
The facility failed to provide adequate supervision, resulting in multiple resident-to-resident altercations. A resident with severe cognitive impairment was struck by another resident with behavioral issues due to being left unsupervised. In a separate incident, another resident was physically assaulted by a fellow resident, highlighting insufficient monitoring. Staff interviews revealed challenges in supervision due to staffing constraints, despite the facility's policy emphasizing residents' rights to be free from abuse and neglect.
A facility failed to provide adequate supervision, resulting in resident-to-resident altercations. One resident with severe cognitive impairment was struck by another resident with behavioral issues, while another resident was physically assaulted in the dining room. Staff interviews revealed a lack of awareness and insufficient staffing to monitor residents effectively, despite protocols for monitoring those with behavioral issues.
A resident with chronic respiratory conditions was found without oxygen, leading to labored breathing and low oxygen saturation. A CNA in training was responsible for the resident's care but was not certified to administer oxygen. An RN noticed the issue but did not immediately assess the resident. The facility's policies require licensed personnel to administer oxygen, which was not followed, resulting in the resident's critical condition.
Failure to Protect Resident from Staff Physical Abuse
Penalty
Summary
The facility failed to protect a resident with moderate cognitive impairment and multiple medical conditions, including palliative care needs, muscle spasms, diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder, from staff-to-resident physical abuse. The resident had been admitted with significant medical diagnoses and was documented as having a BIMS score of 11. During an evening transfer from a wheelchair, staff observed the resident slipping from the chair with both knees locked and her body rigid while staff attempted to reposition her safely. According to the resident’s progress note and the facility’s investigation materials, a CNA and an LPN were assisting the resident when the resident remained stiff and could not bend her legs. The CNA reported that the LPN tapped or smacked the resident’s leg in an attempt to get her to bend her knees. Other statements in the investigation described the LPN as yelling at the resident to relax her legs and hitting or punching her legs until they relaxed. The resident later told staff that the nurse had hit her leg and that she could not help the stiffness. A roommate also reported hearing a nurse yelling at the resident. The facility’s investigation included interviews with staff and the resident’s family, and the written statements collected by the facility contained conflicting descriptions of the event, including that the nurse struck, smacked, jabbed, or touched the resident’s leg during the transfer. The resident was later found to have bruising on both knees and red spots on her arms, with notes indicating she believed she had bumped into things. The facility ultimately documented the allegation as unsubstantiated, despite the resident’s report, the witness account, and the additional statements describing the nurse striking the resident during care.
Abuse Allegation Not Thoroughly Investigated
Penalty
Summary
The facility failed to implement its abuse policy after an incident involving a staff member and Resident #96. Resident #96 was admitted with multiple diagnoses including palliative care, muscle spasms, atherosclerotic heart disease, cervical cancer, type 2 diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder. A Medicare 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive impairment. During the incident, the resident was found slipping from her wheelchair with both knees locked and her body rigid while staff attempted to reposition her. The resident was repeatedly instructed to relax and bend her knees, and she was later assisted to bed for safety. The clinical record and investigation documents showed conflicting accounts of what occurred during the transfer. One staff witness reported that the LPN tapped or smacked the resident’s leg to get her to bend her knees, while the resident later told staff that the nurse hit her leg until it relaxed. Another staff member documented that the resident said the nurse was yelling and hitting her legs, and the resident became tearful and stated that the incident made her feel like no one cared about her and that she was not wanted at the facility. The resident’s family members also reported that they were told the nurse had hit or jabbed the resident’s leg during the transfer. The facility’s investigation was incomplete and inconsistent with its own policy. The investigation was initially determined to be unsubstantiated, with the conclusion that no policies were broken, despite witness statements and resident interviews describing physical contact to the resident’s leg during the transfer. The investigation also omitted written witness statements that were later requested and obtained, including statements from staff who reported that the resident said she had been hit and that the nurse had struck or smacked her leg. The facility policy required all allegations of abuse to be thoroughly investigated, including interviews with staff who had contact with the resident, witnesses, the reporting person, and the resident or representative, and required written, signed, and dated witness statements.
Delayed Reporting of Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of staff-to-resident abuse involving Resident #96 was reported within the required timeframe. Resident #96 was admitted with multiple diagnoses including palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder. A Medicare 5-Day MDS showed a BIMS score of 11, indicating moderate cognitive impairment. On the evening of the incident, a CNA responded to the resident’s call light and found her slipping from her wheelchair with both knees locked and her body rigid. Nursing assistance was requested, and the resident was repeatedly instructed to relax and bend her knees so she could be safely repositioned. The resident was later assisted to bed for safety. The facility’s investigation later documented that the CNA and an LPN were assisting the resident during a two-person transfer and that the LPN tapped the resident’s right shin in an attempt to encourage her to bend her legs. The resident’s family later reported that the nurse had hit the resident’s legs and that a police report had been filed. The investigation showed that the allegation was not reported until the next morning, rather than immediately or within two hours as required by facility policy and as stated by multiple staff members during interviews. Staff interviews reflected that abuse allegations were expected to be reported right away to supervision and administration, and the DON and OM both stated that the incident occurred the prior evening but was not reported until the following morning. Review of the facility’s abuse policy stated that suspicion of abuse must be reported immediately to the administrator and other officials according to state law, with immediate reporting defined as within two hours of an allegation involving abuse or serious bodily injury.
Incomplete Investigation of Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with multiple diagnoses including palliative care, muscle spasms, atherosclerotic heart disease, cervical cancer, type 2 diabetes, hypertension, urinary incontinence, a sacral pressure ulcer, polyneuropathy, and generalized anxiety disorder. The resident had a BIMS score of 11, indicating moderate cognitive impairment. On the evening of the incident, the resident activated her call light and was found by a CNA slipping from her wheelchair with both knees locked, gripping the armrests, and showing generalized body rigidity while staff attempted to reposition her. The clinical record and investigation materials described conflicting accounts of what occurred during the transfer. One staff note documented that the resident was rigid, was instructed multiple times to relax and bend her knees, and was eventually repositioned after she relaxed. The facility investigation later recorded that the CNA reported the LPN tapped the resident’s shin area to encourage her to bend her legs, while other witness statements described the nurse as smacking or hitting the resident’s legs and yelling at her to relax. The resident reportedly told staff that the nurse hit her legs until they relaxed, and a skin assessment documented bruising on both knees and red spots on both arms. The investigation was incomplete because the facility did not include all relevant written witness statements in the final investigation packet. Interviews and written statements from staff who had contact with the resident and who described the resident reporting abuse were not fully incorporated into the facility’s investigation record. The DON and OM acknowledged that leaving staff statements out meant the investigation was not thorough, and the OM stated that pieces were left out of the investigation. The facility ultimately determined the allegation was unsubstantiated despite the resident’s report, the witness account, and the additional staff statements describing the resident saying she had been hit.
Failure to Protect Residents from Abuse and Report Allegations
Penalty
Summary
The facility failed to protect residents from abuse by other residents and a visitor/family member, affecting three sampled residents. One resident with dementia, wandering, impaired vision, and need for supervision was repeatedly documented as wandering into other residents’ rooms and hallways. Another resident had diagnoses including dementia, major depressive disorder, schizophrenia, anxiety disorder, hallucinations, and blindness, and had a care plan for physical and verbal aggression toward other residents and wandering. On April 30, 2023, staff reported a physical altercation in which the second resident stated she pulled the first resident’s hair because the first resident kept coming into her room. The two residents were separated, and staff documented that neither had visible injury. Interviews later confirmed that pulling hair would be considered physical abuse, and the DON stated the perpetrator’s care plan had not been evaluated or updated regarding the incident. The facility also failed to document and report an alleged abuse incident involving a resident and that resident’s son. A resident with dementia, diabetes, depression, and anxiety had a care plan for impaired cognition and communication problems. Another resident with diabetes, anemia, depression, opioid dependence, and PTSD reported concerns to nursing after hearing loud yelling and cursing coming from the first resident’s room and then encountering the resident’s son in the hallway. Multiple written statements described the son using foul language, yelling, and speaking aggressively toward staff and residents, including the reporting resident. The clinical record contained no nursing progress note documenting the allegation, no evidence that the nurse reported it to a supervisor, and no evidence that the provider was notified, although a later NP note referenced an incident involving the son. Facility staff interviews and policy review showed that abuse included physical and verbal abuse, including hair pulling, cursing, yelling, and threatening behavior, and that allegations should be documented and reported. The DON, LPN, and CNA all stated that the incidents described would meet the definition of abuse and that abuse allegations should be entered in the clinical record and escalated. The facility’s abuse policies stated that residents have the right to be free from abuse by other residents, visitors, family members, or any other person in the facility, and that all possible incidents of abuse should be identified, investigated, and reported within required timeframes. The deficiency was based on the facility’s failure to protect residents from these incidents and failure to document and report the allegations as reflected in the records and interviews.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of abuse allegation investigations to the state survey agency within 5 working days of the incident for 2 sampled residents. The deficiency involved an allegation that one resident pulled another resident’s hair after the second resident repeatedly entered the first resident’s room. The report states that the facility did not provide evidence that the investigation results were submitted to the State Agency within the required timeframe, and the State Agency Complaint Tracking System showed no evidence that the investigation had been submitted within 5 working days. Resident #92 had diagnoses including Type 2 diabetes mellitus, dementia, and blindness of one eye. Clinical records showed the resident had a history of wandering, needed redirection back to the room, and required supervision. On the day of the incident, a CNA heard a scream and found Resident #92 in a wheelchair just outside Resident #12’s room. Resident #12 stated that she pulled Resident #92’s hair because Resident #92 kept coming into her room. The note stated that the residents were separated and that neither had visible markings or signs of injury. Resident #12 had diagnoses including dementia, major depressive disorder, schizophrenia, anxiety disorder, hallucinations, and blindness. An admission MDS showed a BIMS score of 14 and no evidence of behavioral symptoms related to physical or verbal behaviors directed toward others. The facility documented that the provider, DON, case manager, and the residents’ families were notified, and that a police report was initiated and statements were taken. However, the facility was unable to provide evidence that the completed investigation and findings were submitted to the state survey agency within 5 working days, and the State Agency Complaint Tracking System showed no evidence of such submission.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were thoroughly investigated for two residents involved in an incident in which one resident pulled the other resident’s hair. Resident #92 had diagnoses including type 2 diabetes mellitus, dementia, and blindness in one eye, with records showing wandering behavior, need for redirection, short- and long-term memory problems, and severely impaired daily decision making. Resident #12 had diagnoses including dementia, major depressive disorder, schizophrenia, anxiety disorder, hallucinations, and blindness, and the care plan identified physical and verbal aggression toward other residents, wandering, and a need to keep the resident from being within arm’s reach of other residents. Clinical documentation showed that staff heard a scream and found Resident #92 in a wheelchair outside Resident #12’s room. Resident #12 stated that she pulled Resident #92’s hair because Resident #92 kept coming into her room. The residents were separated, neither had visible injury, and the provider, DON, case manager, and families were notified. The note also stated that a police report was initiated, statements were taken, and both residents would be monitored and kept at a safe distance. The facility submitted a Facility Reported Incident to the State Agency, but survey review found no evidence that the investigation was thoroughly completed or that the completed investigation results were submitted within 5 working days of the incident. The Administrator stated the facility did not keep internal incident or risk management reports after 12 months following completion, and the DON stated the facility would not be able to provide proof of a thorough investigation because the reports were not kept over 1 year. Review of the State Agency Complaint Tracking System showed no evidence that the investigation had been submitted to the State Agency, despite facility policies requiring abuse allegations to be promptly reported and thoroughly investigated, with written findings provided to the appropriate agencies within five working days.
Insufficient Nursing Staffing and Weekend Coverage
Penalty
Summary
The facility failed to ensure there was sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift. The deficiency was based on review of the facility assessment, facility documentation, interviews, policy review, and PBJ staffing data. The PBJ Staffing Data Report showed the facility consistently triggered for excessively low weekend staffing for all four quarters in 2025 and the first quarter of 2026. The facility assessment reviewed on June 9, 2026, showed the facility was licensed for 104 residents, had an average daily census of 78 to 85, and had an average of 3 to 6 weekday admissions and 1 to 2 weekend admissions, with 2 to 5 weekday discharges and 0 to 3 weekend discharges. The staffing plan called for a full-time DON, full-time ADON, 3 full-time RN/LPNs on the AM shift, 1 CNA for 10 to 13 residents on the AM shift, 2 full-time RN/LPNs on the PM shift, and 1 CNA for 13 to 16 residents on the PM shift. Review of daily staffing assignments showed multiple days in May and June 2026 when staffing did not match the facility assessment. Examples included 2 RN/LPNs on the AM shift for census levels of 71 to 78, resulting in 35 to 39 residents per nurse, and 4 to 5 CNAs caring for 18 to 19 residents each on some shifts. Several schedules also showed no [NAME] assigned on certain shifts, while other days had only 1 [NAME] assigned. On June 5, 2026, 4 RN/LPNs were scheduled on the AM shift and the DON and ADON were also scheduled, while other days still reflected reduced staffing. Weekend staffing was repeatedly lower than weekday staffing. Interviews confirmed ongoing staffing shortages. An RN stated staffing was low for nurses and CNAs, that it was typical to have a caseload of 35 plus residents during a shift, that some tasks such as full vital signs and weights were often missed, and that CNAs often did not take lunch breaks. An LPN stated there was a struggle with staffing nurses and CNAs and that she often did not take breaks or lunches and stayed past her shift to finish tasks. The Staffing Coordinator/CNA stated staffing was done "in my head," had not used a computer program, and did not know what the facility assessment was. The DON and Administrator stated staffing was adequate, but the Administrator acknowledged the facility was short staffed on weekends and that the schedule did not match the facility assessment. The facility policy stated sufficient nursing staff must be provided and licensed nurses must be scheduled to supervise nurse aides with adequate time to do so.
Medications Left Unsecured in Resident Rooms Without Self-Administration Authorization
Penalty
Summary
Drugs and biologicals were not consistently stored in a secure manner and were left accessible in resident rooms without evidence that the residents were authorized to self-administer them. The facility’s policy required medications to be stored in locked compartments and, for residents permitted to self-administer, to have an order, assessment, care plan, and secure storage arrangement documented in the record. Surveyors found that these requirements were not followed for multiple residents. For one resident with bipolar disorder, dementia, psychotic disturbance, anxiety, and hypertension, a bottle of Nystatin topical powder was observed on the bedside table. The resident stated she did not know the medication was there or what it was for. Staff stated that medications should not be at bedside and that Nystatin was a medication that should not have been left there. The DON reviewed the record and stated there was no current order for the Nystatin, no assessment for self-administration, and no care plan entry for self-administration. For another resident admitted for respite care with weakness, an unstageable sacral pressure ulcer, hypertension, and glaucoma, a container labeled as antifungal powder was found in the room by the vanity sink. Staff identified it as the resident’s bottle and stated it should not have been left in the room. The DON reviewed the record and stated there were no orders, current or past, for the antifungal powder and no assessment for self-administration. Staff also stated that leaving the medication at bedside could lead to misuse or ingestion. A third resident with vascular dementia, type 2 diabetes, and major depressive disorder had a cup with six pills left unattended in the room on a meal tray while the resident was lying in bed and no staff were present. The CMA stated she left the medications in the room and identified them as Eliquis, aspirin, vitamin D3, amlodipine, glipizide, and Cardivol, although the record did not contain orders for Cardivol or amlodipine. Staff stated the facility expected nurses or medication staff to remain with residents until medications were taken and that there was no evidence of an order, assessment, or care plan for self-administration. For a fourth resident with spastic hemiplegic cerebral palsy, epilepsy, and GERD, a plastic cup containing Tums was observed on a dresser in the resident’s room. The resident said the nurse had given the medication to her but she had not yet taken it. The CMA stated she had left the Tums in the room and believed the resident could self-administer, but the record contained no order, assessment, or care plan authorizing self-administration. The DON stated that Tums was considered a medication and should not be left at bedside without the required documentation and secure storage arrangement.
Failure to Follow Hold Parameters for Insulin and Blood Pressure Medication
Penalty
Summary
The facility failed to provide treatment and care according to physician orders for a resident with essential hypertension, type 2 diabetes mellitus, and end stage renal disease requiring hemodialysis. The resident’s care plan directed staff to administer diabetes and antihypertensive medications as ordered, obtain fasting blood sugar tests as ordered, and take blood pressure readings under the same conditions each time using the resident’s right arm. The resident’s MDS assessment showed a BIMS score of 12, indicating moderately intact cognition, and documented use of hypoglycemic medications including insulin. Physician orders included Insulin Glargine 15 units subcutaneously daily for diabetes, to be held if blood glucose was less than 110, and Isosorbide Mononitrate ER 30 mg, 2 tablets daily for hypertension, to be held if systolic blood pressure was less than 110. Review of the MAR showed multiple instances where these medications were administered despite values below the ordered hold parameters. The insulin was given on several occasions when blood glucose ranged from 85 to 109, including readings of 109, 95, 92, 85, 93, 103, 108, 105, and 96. The isosorbide was administered when systolic blood pressure was 99, 105, and 99, despite the hold order. During interviews, an RN stated that she should check the resident’s medication profile, vital signs, and contraindications before administering medications, and that insulin should be held when blood glucose is below the ordered parameter. The DON stated that staff were expected to follow physician orders and that giving insulin below the ordered blood glucose parameter could lead to hypoglycemia, while giving the blood pressure medication below the ordered systolic parameter could cause hypotension. The DON reviewed the MAR and confirmed that the documented administrations did not follow the orders.
Improper Foley Catheter Positioning and Care
Penalty
Summary
The facility failed to ensure appropriate catheter care and urinary tract infection prevention for two residents with indwelling Foley catheters. Resident #1 had diagnoses including diabetes, end stage renal disease, bacteriuria, urinary tract infection, dementia, and obstructive/reflux uropathy, and the MDS indicated severe cognitive impairment and an indwelling catheter. Physician orders required catheter care with soap and water or wipes and changing the drainage bag as needed, and the care plan directed that the catheter bag and tubing be positioned below the bladder and monitored for pain or discomfort. During an observation, Resident #1 was being transported in a wheelchair when the catheter bag was run over by the wheelchair and was observed dragging on the floor while the resident said “ouch.” The bag continued to drag on the floor during transport, and the resident was left seated with the bag still touching the floor. Staff interviewed afterward stated that the bag should not have been touching the floor, that it should be secured off the ground, and that if a catheter bag is run over the catheter should be changed. The DON stated that the catheter bag was not changed immediately after the event, but was changed later in the day. Resident #2 had diagnoses including chronic kidney disease, obstructive and reflux uropathy, and retention of urine, and the MDS indicated moderate cognitive impairment and an indwelling catheter. Orders required catheter care with soap and water or wipes, changing the Foley catheter and drainage bag as needed, and enhanced barrier precautions. On two separate observations, the catheter bag was seen making direct contact with the floor while the resident was in bed with the bed in the lowest position. Staff interviews confirmed the bag should not be on the floor and should remain below the bladder. The DON and nursing staff also observed that the drainage spout was touching the floor and that the bag anchor was broken. Review of the TAR showed catheter care was performed twice daily, with no replacement of the catheter bag or tubing documented during the reviewed period.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from abuse by other residents, resulting in multiple resident-to-resident altercations. All residents involved were severely cognitively impaired, as indicated by their BIMS scores of 99 and diagnoses including dementia with behavioral disturbances, vascular dementia, and major depressive disorder. In one incident, a resident awoke to find a broken shoelace and responded by physically assaulting another resident, who then retaliated. This altercation was witnessed by a staff member who intervened, but not before a minor injury occurred. In another event, a resident accused another of theft and responded by slapping the other resident multiple times, despite staff attempts to de-escalate the situation. No stolen items were found, and the altercation was stopped by staff intervention. A third incident occurred when two residents' wheelchairs became entangled, leading one resident to punch the other in the face before staff could separate them. The assaulted resident was left with visible facial discoloration. Facility investigations substantiated all three incidents, confirming that the residents were not adequately protected from abuse by other residents.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision for residents, leading to multiple resident-to-resident altercations. Resident #1, who has severe cognitive impairment and a history of behavioral disturbances, was struck by another resident, Resident #2, who also has dementia and behavioral issues. Despite interventions in place to manage their behaviors, both residents were left unsupervised in the dining area, resulting in an altercation where Resident #1 was punched by Resident #2. Staff interviews revealed that the residents were left alone for approximately 20 minutes, and there was a lack of awareness among staff about the incident, indicating insufficient supervision and monitoring. In another incident, Resident #3, who has severe cognitive impairment and is at risk for abuse, was physically assaulted by Resident #4. Resident #4, who also has cognitive impairments, was observed tugging at Resident #3's wheelchair and subsequently punched her multiple times. The incident was witnessed by staff, who intervened to separate the residents. However, the facility's investigation revealed that Resident #4 continued to exhibit aggressive behavior, and there was a lack of effective supervision to prevent such incidents. Interviews with staff, including the CNA and LPN, highlighted challenges in monitoring residents due to staffing constraints. The LPN noted that it was difficult to supervise residents while attending to other duties, and the CNA was unaware of the previous altercations. The Director of Nursing acknowledged the need for supervision to prevent aggression but believed there was sufficient staff, despite evidence to the contrary. The facility's policy emphasizes the right of residents to be free from abuse and neglect, yet the incidents demonstrate a failure to uphold these standards, resulting in a deficiency in resident supervision.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations, as evidenced by incidents involving four residents. Resident #1, who has severe cognitive impairment and a history of behavioral disturbances, was struck by Resident #2, who also has dementia and behavioral issues. Despite interventions in place, such as administering medications and monitoring behaviors, the residents were left unsupervised in the dining area, leading to the altercation. Staff interviews revealed a lack of awareness of the incident and insufficient staffing to monitor residents effectively. In another incident, Resident #3, who has severe cognitive impairment and is at risk for abuse, was physically assaulted by Resident #4. The altercation occurred in the dining room, where Resident #4 was observed tugging at Resident #3's wheelchair and subsequently hitting her. Staff intervened to separate the residents, but the incident highlighted the lack of supervision and monitoring, as Resident #4 was able to approach and assault Resident #3 without immediate intervention. Interviews with staff, including a CNA and the Director of Nursing, indicated that there is a protocol for monitoring residents with behavioral issues, but it was not effectively implemented. Staff reported challenges in supervising residents due to insufficient staffing, particularly when some residents require two-person assistance. The facility's policy emphasizes the importance of resident safety and supervision, yet the incidents demonstrate a failure to adhere to these guidelines, resulting in resident-to-resident altercations.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident with chronic obstructive pulmonary disease and other respiratory conditions. The resident was supposed to receive oxygen therapy to maintain saturation levels above 90%, as per physician orders. However, during an incident, the resident was found without oxygen, leading to labored breathing and a significant drop in oxygen saturation to 57%. This situation occurred while the resident was being taken to breakfast by a CNA, who was not certified to administer oxygen. The incident involved a CNA who was in training and not certified to handle oxygen administration. The CNA was responsible for ensuring the resident's oxygen was connected, but the resident was found without the nasal cannula connected to the oxygen source. A registered nurse (RN) noticed the resident's condition but did not immediately assess the resident or ensure the oxygen was administered correctly. The resident was eventually taken back to her room, and emergency services were called after her condition was assessed. Interviews with staff revealed a lack of clarity regarding the responsibilities of CNAs and nurses in administering oxygen. The Director of Nursing stated that it was the responsibility of the RN and LPN to ensure oxygen was administered correctly and that CNAs should not administer oxygen. The facility's policies also indicated that only licensed personnel should administer medications, including oxygen, highlighting a failure in following these protocols, which led to the resident's critical condition.
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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 Globe
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Health Care Center | 0.6 mi | ★★★★★ | 6 | 0 |
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