Haven Hall Health Care Center

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure the Payroll-Based Journal (PBJ) report for the October 1 through December 31 reporting period was submitted accurately and within the required Centers for Medicare & Medicaid Services (CMS) timeframe for one (1) of four (4) quarters reviewed.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure residents received care and services in accordance with professional standards of practice and physician oversight. Specifically, the facility failed to clarify and obtain appropriate physician guidance regarding administration of blood pressure medications prior to dialysis and failed to follow safe medication administration practices, resulting in the resident receiving medications that had the potential to cause hypotension during dialysis one (1) of (1) residents reviewed for dialysis care. Resident #14Findings Include: Record review of the facility policy Administering Medications dated 2001 revealed Medications are administered in a safe and timely manner and as prescribed . 8. [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review the facility failed to provide complete perineal (peri-care) for one (1) of two (2) residents observed for incontinent care. Resident #26Findings Include:Record review of the facility's policy Cather Care, Urinary dated 8/2022 revealed, .Routine Perineal Hygiene: 1. Wash basin, soap and water and washcloths; OR 2. Bathing wipes 3. Towels;4. Bed protector. Steps.1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the basin over half (1/2) full of warm water (or if using bathing wipes, open the package). 4. Place the wash basin or wipes on the bedside stand within easy reach. 5. Put on gloves. [...]

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to implement and maintain an effective infection prevention and control program to prevent the spread of infection, as evidenced by improperly stored and dated oxygen (O2) tubing for Resident #1, incomplete perineal care for Resident #26 and improper handling of food items for Resident #27 for two (2) of three (3) days of survey.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to store and replace oxygen tubing in accordance with professional standards and facility policy for one (1) of two (2) residents reviewed for oxygen use. Resident #1.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure nursing staff were competent to perform duties related to safe medication administration and clinical decision making for one (1) of (1) residents reviewed for dialysis related care. Resident #14 Findings Include: Record review of the facility policy Administering Medications dated 2001 revealed Medications are administered in a safe and timely manner and as prescribed . 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having a potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to express concerns. 21. [...]

Inspectors wroteBased on interviews and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll-Based Journal (PBJ) data, containing staffing hours for the appropriate care of residents, was corrected before submission to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters in 2024. 3rd (Third) Quarter Findings Include: A review of the facility policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), revised August 2022, revealed, . Complete and accurate direct care staffing information is reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure care plan interventions related to Enhanced Barrier Precautions (EPB) were implemented for two (2) of three (3) residents reviewed with indwelling devices. Residents #25 and #33 Findings Include: A review of the facility's policy titled, Using the Care Plan, (undated), revealed, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or serviced to the resident . Resident #25: A record review of Resident #25's Comprehensive Care Plan, with a date initiated of 5/26/23 revealed . receives PEG (Percutaneous Endoscopic Gastrostomy) tube feeding . Interventions . Maintain set Enhanced Based Precautions, such as washing hands, wearing a gown, wearing gloves, etc. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed by staff when providing direct care for residents with indwelling devices for two (2) of three (3) residents reviewed with indwelling devices. Residents #18 and #25 Findings Include: A review of the facility's policy titled, Enhanced Barrier Precautions, (undated) revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs) . Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents colonized or infected with MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices) . [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to provide pressure ulcer treatment in a manner to prevent cross contamination and the potential for spread of infection for one (1) of six (6) sampled residents, Resident #1. Findings Include: Record review of the facility policy titled Dressings, Dry/Clean, with revised September 2013, revealed, .Steps in the Procedure .5. Wash and dry your hands thoroughly. 6. Put on clean gloves. Loosen tape and removed soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Wash and dry your hands thoroughly .11. Using clean technique, open other products. 12. Wash and dry your hands thoroughly. 13. Put on clean gloves . [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection by not placing supplies outside the residents door and by not posting appropriate signage to alert staff and visitors of necessary precautions for one (1) of two (2) residents observed for Transmission-Based Precautions (TBP). Resident #68.