Haven Manor Health Care Center, LLC

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the residents' right to a safe, clean, and comfortable environment. This was evident on the 6th Floor. Specifically, observation on the 6th Floor include but is not limited to stained ceiling tiles in some of residents' rooms, radiators were rusted and the base had cracks, window blinds had stains, bedside tables were dirty.

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification Survey from 01/15/2026 to 01/23/2026, the facility did not ensure residents had a right to make choices regarding aspects of their life for two (2) of two (2) residents out of 38 residents reviewed for smoking. Specifically, the facility did not allow the residents to go out and smoke and did not offer a smoking cessation program for Resident # 103 and Resident #102, who were known smokers at the time of admission.

Inspectors wroteNumber of residents sampled: 3Number of residents cited: 1 Based on record review and interviews, the facility did not ensure that a resident or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for one (1) resident (Resident #216) of three (3) residents reviewed for Beneficiary Notification. Specifically, there is no documented evidence that the Notice of Medicare Non-Coverage form was mailed to Resident #216's designated representative on the same day the telephone notification was made.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents' rights to privacy and confidentiality were maintained. This was evident for one (1) (2nd Floor) of two (2) units observed for medication administration. Specifically, Licensed Practical Nurse #3 walked away from the medication cart without locking the laptop computer exposing Resident #136's medical record.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from any physical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for two (2) residents (Resident #143 and Resident #141) of three (3) residents investigated for Physical Restraint. Specifically, 1). Resident #143 was observed wearing a seat belt in wheelchair and Resident #143 stated they did not know how to remove the seat belt, and staff had to remove it. 2). Resident #141 was observed with a lap seat belt affixed while seated in a wheelchair on multiple occasions. Resident #141 was not able to remove the seat belt on their own.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a copy of the discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman. This was evident for one (1) of one (1) resident (Resident #214) reviewed for Discharge. Specifically, there was no documented evidence that a copy of Resident #214's discharge notice was sent to the Office of the State Long-Term Care Ombudsman.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for two (2) of 4 (four) (Residents #141 and #143) residents observed for restraints. Specifically, Residents #141 and #143 was observed on multiple occasions wearing seatbelts. There was no care plan developed for both residents to address ongoing use of restraints. Cross Reference F-tag 604: Right to be Free from Physical Restraints

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a resident who was administered enteral tube feedings received the appropriate treatment and services to prevent complications. This was evident in two (2) of two (2) (Residents #10 and #12) residents reviewed for tube feeding out of 38 total sampled residents. Specifically, Residents #10 and #12's enteral tube feeding formula and water bag were not labeled with the resident's name, the date and start time of the administration.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that medication and biologicals drugs were labeled in accordance with currently accepted professional principles on the Medication Cart on the 4th floor. Specifically, Residents #119 and #186's eye drops did not have the resident's name on the vial. This was evident for one (1) (4th Floor) of five (5) units reviewed for Medication Storage.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for one (1) of three (3)(Licensed Practical Nurse #3) nurses observed during medication administration. Specifically, Licensed Practical Nurse #3 failed to sanitize the sphygmomanometer (an equipment used to take blood pressure) and the blood pressure cuff before and after use and in between residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide a safe and comfortable environment for the staff. This was evident during physical environment observation in the laundry room on the basement and the 6th Floor nurses' station.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that Minimum Data Set assessments accurately reflected the resident's status. This was evident for three (3) of 3 (three) (Residents #141, 100, and 143) reviewed for resident assessment. Specifically, 1.) Resident #141's use of restraint was not accurately documented in the Minimum Data Set assessment. 2.) Resident #100 who had a physician's order for clopidrogel (an antiplatelet drug used to prevent blood clot by preventing platelets from clumping together in the blood), was coded in the Minimum Data Set assessment as receiving anticoagulant. 3.) Resident #143's use of restraint was not accurately documented in the Minimum Data Set assessment. Cross Reference to F-tag 604: Right to be Free from Physical RestraintsThe

Inspectors wroteBased on record review and interviews conducted during the abbreviated survey (#2650673), the facility did not ensure each resident's right to privacy and confidentiality. This was evident for one (1) of three (3) residents (Resident #1) sampled. Specifically, photographs of Resident #1's body and private space were taken without the resident's or designated representative's written consent.

Inspectors wroteBased on observation, record review, and interviews conducted during an abbreviated survey (NY00333004), the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than two hours after the allegation of abuse was made, to the State Survey Agency (New York State Department of Health). This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, on 02/04/24 at 1:00 am, Resident #1 informed the front desk Receptionist that Resident #2 climbed into their bed and took advantage of them. On 02/06/24 at 9:30 am, the facility reported the allegation to the New York State Department of Health, two days after the incident occurred.

Inspectors wroteBased on observation, interview, and record review conducted during the Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure the Director of Nursing (DNS) served as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This was evident for 1 (Unit 5) of 5 Units. Specifically, the DNS was observed working as a charge nurse and administered medication to residents.

Inspectors wroteBased on observation, record review, and interviews conducted during a Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to residents. This was evident for 1 (Unit 2) of 5 resident units. Specifically, rusty bedframes were observed being used for Resident #372 and #152.

Inspectors wroteBased on observations, interview, and record review conducted during the Recertification Survey from 11/08/2023 to 11/15/2023, the facility did not ensure that residents remained free of physical restraints. This was evidenced for 2 (Resident #197, Resident #141) of 6 reviewed for Physical Restraints out of 38 total sampled residents. Specifically, 1) Resident #197 was observed with bilateral upper 1/2 siderails (SR) in place without assessment or Medical Doctor Order (MDO), and 2) Resident #141 was observed with bilateral 1/2 siderails (SR) in place without a restraint assessment or Medical Doctor Order (MDO).

Inspectors wroteBased on record review and interview conducted during the recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure accuracy of resident assessments. This was evident for 2 (Resident #110 and Resident #184) of 38 total sampled residents. Specifically, 1) the Minimum Data Set 3.0 (MDS) assessment for Resident #110 did not accurately reflect the resident's diagnoses, and 2) the MDS assessment for Resident #184 did not include the resident's use of a Wander Alert Device (WAD).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility. This was evident for 1 (Resident #472) of 38 total sampled residents. Specifically, Resident #472 did not have a Preadmission Screening and Resident Review (PASARR) completed prior to their admission to the facility.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure comprehensive care plans (CCP) were reviewed and revised after each assessment. This was evident for 1 (Resident #110) of 38 total sampled residents. Specifically, the CCPs related to Activities of Daily Living (ADL) and psychotropic drug use were not reviewed and revised upon quarterly Minimum Data Set 3.0 (MDS) assessment.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 11/8/2023 to 11/15/2023, the facility did not ensure residents received proper treatment and services to maintain vision abilities. This was evident for 1 (Resident #143) resident of 38 total sampled residents. Specifically, Resident #143 did not receive a Ophthalmology consult in accordance with Medical Doctor Order (MDO).

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure an account of all controlled drugs was maintained as per standard of practice. This was evident for 1 (Unit 6) of 5 Units. Specifically reconciliation of narcotics was performed by 1 Licensed Practical Nurse (LPN).

Inspectors wroteBased on observation, record review, and interview conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure infection prevention and control practices were maintained. This was evident for 1 (Resident #152) of 3 residents reviewed for Pressure Ulcer/Injury, out of 38 total sampled residents. Specifically, the Registered Nurse (RN) failed to practice hand hygiene and glove changes during wound care.

Inspectors wroteBased on record review and staff interviews during the Recertification survey, the facility did not ensure that a surety bond or similar protection with the amount equal to at least the current total amount of resident's funds was purchased. Specifically, the surety bond held by the facility did not cover the total amount of resident personal funds deposited with the facility. This was evident for 165 of 172 residents who maintained personal funds accounts at the facility and was evident during the Personal Funds Facility Task.

Inspectors wroteBased on observation, record review and interview conducted during the Recertification Survey, the facility did not ensure that resident received appropriate care and services for catheter care. Specifically, two residents with suprapubic indwelling catheters did not have their catheters changed as ordered. This was evident for 2 of 3 reviewed for Urinary Catheters or Urinary Tract Infections (UTI) out of a sample of 36 residents, (Resident #73 and Resident #94)

Inspectors wroteBased on observation, record reviews, and interviews conducted during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1). a Housekeeping Aide (HA) did not perform hand hygiene after handling bed linen in resident rooms and before handling clean linen and after removing gloves, and 2). a Licensed Practical Nurse was observed during medication observations using the same tissue to instill eye drops to both eyes of a resident.

Inspectors wroteBased on observation, interviews, and record reviews, conducted during Recertification survey, the facility did not ensure that the residents right to self-determination to make choices are respected. Specifically, the facility smoking program was cancelled on 03/20/2020 and residents were not given the choice to smoke when small group activities resumed. This was evident for 1 out of 4 resident review for Choices (Resident # 168)

Inspectors wroteBased on interview and record review conducted during a recertification and complaint investigation (NY00278371) completed on 8/19/2021, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made, to the State Survey Agency. Specifically, the facility did not report an incident of resident-to-resident physical abuse that occurred on 6/22/2021 to NYSDOH until 6/23/2021. This was evident for 2 of 7 residents reviewed for Abuse (Resident # 101 and Resident # 424). The finding is: The facility policy and procedure titled Abuse Reporting revised 1/2017 documented it is the facility's responsibility to report incidences to the NY DOH as per guidance in the Nursing Home Incident Reporting Manual- August 2016. [...]

Inspectors wroteBased on record reviews, observations, and staff interviews during the recertification survey the facility did not ensure that an incident was thoroughly investigated. Specifically, the facility did not obtain staff statements from all witnesses on the previous shift for an investigation conducted regarding a resident who was transferred to the hospital for evaluation after an allegation of sexual assault. This was evident for 1 out of 7 residents reviewed for Abuse out of 36 sampled residents. (Resident #95). The finding is: The facility policy and procedure titled Abuse Reporting revised 1/2017 documented it is the facility's responsibility to report incidences to the NY DOH as per guidance in the Nursing Home Incident Reporting Manual- August 2016. [...]