DESERT HAVEN CARE CENTER (PHOENIX, AZ) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	21.9%
State:	15.4%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	24.9%
State:	14.8%

Percent of long-stay high-risk residents with pressure ulcers

Here:	6.8%
Arizona:	6.8%

Percent of long-stay residents who lose too much weight

Here:	1.3%
State:	7.1%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	36.8%
Arizona:	55.2%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	2.8%
State:	4.8%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	5.1%
Arizona:	6.8%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	12.8%
State:	4.8%

Percent of long-stay residents who were physically restrained

This Nursing Home:	8.9%
State:	1.0%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	2.5%
Arizona:	3.0%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
State:	96.5%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	89.9%
State:	96.0%

Percent of long-stay residents who received an antipsychotic medication

Here:	70.9%
Arizona:	23.8%

Complaint Deficiency

An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide access to a telephone for resident to use in private
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide doctors orders for the resident's immediate care, at the time the resident was admitted
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A separate and independent backup electrical power source
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide adequate and comfortable lighting levels in all areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Check and assess each resident's assessment at least every 3 months
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that special or therapeutic diets are ordered by the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have enough backup water supply for essential areas of the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Employ or obtain outside professional resources providing services in the nursing home that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Potential for minimal harm
- Scope: Some
Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Potential for minimal harm
- Scope: Many
Send and promptly deliver unopened mail to residents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have enough outside ventilation via a window or mechanical ventilation, or both
- Harm: Minimal harm or potential for actual harm
- Scope: Many
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Potential for minimal harm
- Scope: Some
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give notice to the resident before a room or roommate change
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide doctors orders for the resident's immediate care, at the time the resident was admitted
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Put firmly secured handrails on each side of hallways
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridors or aisles that are unobstructed and are at least 8 feet in width
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some

DESERT HAVEN CARE CENTER - PHOENIX, AZ

Quality Measures

Complaint Deficiency

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