Care Haven Center

Inspectors wroteBased on record review and staff interview, the facility failed to develop and/or implement care plans related to Hospice services and meal intake percentages. This failed practice was found true for (3) three of 23 residents reviewed for care plan accuracy during the Long-Term Care Survey Process. Resident identifiers #65, #5, #12. Facility Census 65.

Inspectors wroteBased on resident interview, staff interview, and food tray temperatures, the facility failed to serve food that was palatable and at an appetizing temperature. The facility failed to ensure hot foods were served hot and cold foods were served cold. This practice was true for three (3) of the four (4) hallways tested for milk on the beverage carts and food tray temperatures for two (2) of two (2) meal trays tested throughout the survey process.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. This practice had the potential to affect more than a limited number of residents receiving nourishment from the kitchen. Facility census: 65.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical record related to resident meal percentages. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier #14. Facility census: 65.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. The resident's Peripherally Inserted Central Catheter (PICC line) dressing was not changed in accordance with professional standards of practice. This was true for one (1) of one (1) residents with PICC lines reviewed. Resident Identifier: #30. Facility Census: 65.

Inspectors wroteBased on observation, record review, resident interview, and staff interview the facility failed to follow resident's therapeutic diet for fortified foods. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #14, and #1. Facility census: 65.

Inspectors wroteBased on observations, record review, resident interview, and staff interview, the facility failed to maintain regularly scheduled mealtimes. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census: 64. Findings Included: a) Dining Observation An observation on 09/03/24 at 12:30 PM revealed the lunch meal had not been served. 16 residents were in the dining room waiting for their meal. A review of the posted mealtimes found that the lunch meal was scheduled to start at 12:15 PM daily. An interview with Nurse Aide #29 on 09/03/24 at 12:44 PM revealed the lunch meal was late most days. During an interview, on 09/03/24 at 12:56 PM, Certified Dietary Manager (CDM) verified the noon meal was not served on time. She stated breakfast was late so they could not start on time for the lunch meal. [...]

Inspectors wroteBased on observation and staff interview the facility failed to serve food in accordance with professional standards for food serve safety. This had the ability to effect more than a limited number of residents. Facility census: 64.

Inspectors wroteBased on observation, and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: #119. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #25. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to protect the personal privacy and confidentiality of residents ' medical records. This was true for two (2) residents as a random opportunity for discovery. Resident identifiers: #47 and #59. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to report alleged violation related to, neglect, or abuse, and report the results of all investigation to the proper authorities within prescribe time-frames. This was a random opportunity for discovery. Resident identifier: #8. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for Resident #15 that was trauma-informed and would allow Resident #15 to attain or maintain his highest practicable physical, mental, and psychosocial well-being. This was true for one (1) of three (3) residents reviewed for the diagnosis of Post Traumatic Stress Disorder (PTSD). Resident identifier: #15. Facility census: 64.

Inspectors wroteBased on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure one (1) residents received treatment and care in accordance with professional standards of practice. Resident identifier: #30. Facility census: 64.

Inspectors wroteBased on staff interview and medical record review the facility failed to ensure Resident #92 received assistance with meals. This was true for one (1) of (1) residents reviewed for nutrition. Resident identifier #119. Facility census: 64.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure one (1) of one (1) residents reviewed for nutrition received the correct therapeutic diet. Resident #119. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate records on two (2) out of 22 sampled residents in the Long-Term Care Survey Process. Resident identifiers: #64 and #119. Facility census: 64.

Inspectors wroteBased on record review and staff interview, the facility failed to address resident preference and potential for future discharge within resident care plans. This was true for Residents #55, #46, and #12. The facility also failed to develop a care plan for non-pharmacological interventions for pain. This was true for Residents #164 and #42. The facility's failure to ensure accurate comprehensive care plans was true for five (5) of 21 sampled residents in the long-term care survey process. Resident identifiers: #55, #46, #12, #164, and #42. Facility census: 67. a) Resident #12 A record review, completed on 02/27/23 at 9:04 PM, revealed the care plan did not address Resident #12's preference and potential for future discharge. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice regarding parameters for pain medications. This was true for four (4) of four (4) residents reviewed for pain. Resident identifiers: #28, #164, #56, #42. Facility census: 66.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for four (4) of nine (9) sampled residents reviewed in the Long-Term Care Survey process. Resident identifiers: #16, #34, #55, and #45. Facility census: 67.

Inspectors wroteBased on observations, policy review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases including Covid-19 and infections with regards to Resident handwashing, Resident Covid -19 screening not completed accurately (Vital Signs) and storing a used bed pan on the bathroom floor. This has the potential to affect more than a limited number of residents in the facility. Resident identifiers: #28, #56 and #146. Facility census: 66.

Inspectors wroteBased on observation and staff interview, the facility failed to treat one (1) of the 21 sampled residents in the long-term care survey process with dignity and respect. The facility failed to honor Resident #46's right to a dignified existence prior to beginning an activity in a public area. Resident Identifier: #46. Facility Census: 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to honor Resident #56's right to direct her own medical care. This was true for one (1) of nine (9) residents reviewed for Advance Directives. Resident identifier #56. Facility census: 66.

Inspectors wroteBased on record review and staff interview, the facility failed to honor Resident #16's privacy when taking a skin and wound assessment picture . This was a random opportunity for discovery. Resident identifier: #16. Facility census: 67.

Inspectors wroteBased on interview and record review the facility failed to follow up on a grievance regarding lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56. Facility census: 66. Findings Included: a) Resident #56 On 02/22/23 at 11:08 AM during an interview Resident #56's Health Care Surrogate (HCS) stated that he reported her dentures missing about three weeks ago to the facility. He stated that he asks about the dentures every time he visits, and the staff states that they are looking for the dentures. A review of the facility concerns, and grievance log found no issue for Resident #56's lost dentures. During an interview on 02/28/23 at 3:47 PM the Social Worker (SW) stated that she had heard about Resident #56's missing dentures. She continued to say that she though they had found them. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide care and services in accordance with acceptable standards of practice. This was true for one (1) out of 21 residents sampled during the annual recertification survey. Resident identifier: #45. Facility Census: 67.

Inspectors wroteBased on interview and record review the facility failed to provide prompt dental treatment for lost dentures. This is true for one (1) of two (2) reviewed for dental care during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #56. Facility census: 66. Findings Included: a) Resident #56 On 02/22/23 at 11:08 AM during an interview Resident #56's Health Care Surrogate (HCS) stated that he reported her dentures missing about three weeks ago to the facility. He stated that he asks about the dentures every time he visits. The staff states that they are looking for the dentures. A review of the facility concerns, and grievance log found no issue for Resident #56's lost dentures. During an interview on 02/28/23 at 3:47 PM the Social Worker (SW) stated that she had heard about Resident #56's missing dentures. She continued to say that she though they had found them. [...]