SAFE HAVEN CARE CENTER OF POCATELLO

Nursing Home Inspector

1200 HOSPITAL WAY
POCATELLO, ID 83201
Bannock County
Phone: 208-232-2570
Provider Number: 135071
Last Inspection: 04/15/2016

About the Nursing Home

Number of Beds: 84
Number of Residents: 79
Beds Available: 5
Percent Occupancy: 94%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Individual
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

41

Facility
15

County
28

ID
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

41

2016
76

2015
73

2013

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/15/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 9/23/2016
 
Failed To: Provide residents with private access to a telephone. Isolated : Minimal 3 7/15/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 7/15/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 9/23/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 9/23/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 9/23/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 9/23/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 9/23/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Actual 4 9/23/2016
 
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Widespread : Minimal 5 7/15/2016
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Pattern : Minimal 4 7/15/2016
 

1/16/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 2/20/2015
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 2/20/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 2/20/2015
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 2/20/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 2/20/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 2/20/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 2/20/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 2/20/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 2/20/2015
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 2/20/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 2/20/2015
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 2/20/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 2/20/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 2/20/2015
 
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Widespread : Minimal 5 2/20/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 2/20/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 2/20/2015
 
Failed To: Dispose of garbage and refuse properly. Pattern : Minimal 4 2/20/2015
 
Failed To: Put firmly secured handrails on each side of hallways. Pattern : Minimal 4 2/20/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 2/20/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 2/20/2015
 

10/11/2013 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 2/25/2014
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 12/11/2013
 
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 2/25/2014
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 12/11/2013
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 12/11/2013
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 12/11/2013
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 12/11/2013
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 12/11/2013
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 2/25/2014
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 12/11/2013
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 12/11/2013
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 12/11/2013
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 12/11/2013
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/11/2013
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 2/25/2014
 
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 2/25/2014
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 12/11/2013
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Isolated : Minimal 3 2/25/2014
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 12/11/2013
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/11/2013
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 12/11/2013
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/13/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 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. Isolated : Minimal 3 8/15/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 8/15/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 8/15/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 unknown
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 8/15/2017
 

3/23/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 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. Isolated : Minimal 3 8/15/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 6/12/2017
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern : Minimal 4 6/12/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 8/15/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 9/26/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 8/15/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 6/12/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 6/12/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 8/15/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 6/12/2017
 
Failed To: Use a registered nurse at least 8 hours a day, 7 days a week. Widespread : Minimal 5 6/12/2017
 
Failed To: Make sure that doctors visit residents regularly, as required. Pattern : Minimal 4 6/12/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 8/15/2017
 
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 6/12/2017
 
Failed To: Make sure that a working call system is available in each resident's room or bathroom and bathing area. Isolated : Minimal 3 8/15/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 6/12/2017
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Widespread : Minimal 5 6/12/2017
 
Failed To: Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. Widespread : Minimal 5 6/12/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 8/15/2017
 

6/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 9/15/2015
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 9/15/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 9/15/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 9/15/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 9/15/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 9/15/2015
 
Failed To: Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated : Minimal 3 9/15/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 9/15/2015
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 9/15/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Actual 4 9/15/2015
 
Failed To: Ensure that all full-time nurse aids employed for more than 4 months are fully trained and competent to provide nursing and nursing-related services, as defined by Federal requirements. Pattern : Minimal 4 9/15/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 9/15/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 9/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg ID State Avg
Number of Residents 79 54.60 49.22
Registered Nurses Not Available 0.81 0.87
Licensed Practical / Vocational Nurses Not Available 0.99 0.78
Certified Nursing Assistants Not Available 2.43 2.50
Total Staff Hours Not Available 4.23 4.15

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% ID State Avg%
of high risk long-stay residents with pressure ulcers 0 1 3
of long-stay residents assessed and appropriately given the pneumococcal vaccine 49 89 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 84 95 96
of long-stay residents experiencing one or more falls with major injury 4 2 2
of long-stay residents who have depressive symptoms 25 12 5
of long-stay residents who lose too much weight 11 6 6
of long-stay residents who received an antianxiety or hypnotic medication 47 27 20
of long-stay residents who received an antipsychotic medication 60 18 17
of long-stay residents who self-report moderate to severe pain 20 9 10
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 12 17 17
of long-stay residents whose need for help with daily activities has increased 19 14 15
of long-stay residents with a catheter inserted and left in their bladder 2 2 2
of long-stay residents with a urinary tract infection 7 4 4
of low risk long-stay residents who lose control of their bowels or bladder 49 45 47
of short-stay residents assessed and appropriately given the pneumococcal vaccine 9 80 87
of short-stay residents who had an outpatient emergency department visit 7 10 11
of short-stay residents who self-report moderate to severe pain 39 59 67
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 19 1 1
of short-stay residents who were rehospitalized after a nursing home admission 20 17 20
of short-stay residents with pressure ulcers that are new or worsened 3 76 83