Haven Nursing Center

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free of chemical restraints by failing to ensure a resident had an appropriate diagnosis for the use of an antipsychotic medication for 1 (#13) of 5 residents reviewed for unnecessary medication.

Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice by failing to identify a wound for 1 (#33) of 3 residents reviewed for non-pressure related skin conditions.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for resident needs by not 1) having documentation of a change of condition regarding a resident's low blood pressure and/or low pulse for 1 (#84) of 3 closed records reviewed, and 2) notifying a resident's physician for a high blood sugar reading for 1 (#10) of 1 residents reviewed for insulin.

Inspectors wroteBased on record reviews and interviews, the Pharmacist failed to identify and report irregularities to the attending Physician, the facility's Medical Director and DON for 1 (#13) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 1 (#13) of 5 residents reviewed for unnecessary medications. The facility failed to monitor for edema for Resident #13 while on receiving Lasix (diuretic medication).

Inspectors wroteBased on observations and interview the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to 1) ensure food item packages were sealed and not left open to air, 2) document refrigerator and freezer temperatures, and 3) document steam table food temperatures.

Inspectors wroteBased on observation and interview, the facility failed to provide an infection prevention and control program designed to provide a safe, sanitary and comfortable environment by failing to ensure biohazardous waste was not accessible to unauthorized personnel.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 1 (#35) of 1 sampled residents observed for medications available at the bedside.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote healing and prevent the development of new pressure ulcers for 2 (#7, #30) of 5 (#7, #30, #61, #66, #136) residents investigated for pressure ulcers. The deficient practice was evidenced by the facility failing to provide pressure reducing devices for a resident with a stage 3 pressure ulcer (#7) and for a resident who was at a moderate risk for developing pressure ulcers (#30).

Inspectors wroteBased on record review and interview, the facility failed to maintain acceptable parameters of nutritional status by failing to follow up with the physician in a timely manner to implement the registered dietician's (RD) recommendation for 1 (#14) of 4 (#6, #14, #51, #63) residents reviewed for nutrition.

Inspectors wroteBased on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s medical director not being present for the quarterly meetings reviewed. Review of the (QAA) meetings revealed meetings were held on 01/30/2025, 11/12/2024, 07/30/2024, and 03/28/2024. Review of the attendance roster revealed the medical director`s signature was not recorded on the roster. On 05/07/2025 at 02:25 p.m., an interview with S1 Administrator confirmed the medical director was not present for above quarterly QAA meetings.

Inspectors wroteBased on observations, record review, and interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#73) of 2 (#73, #76) residents reviewed for positioning and mobility. The deficient practice was evidenced by the facility failing to ensure a resident in a geri chair received proper support of her lower extremities.

Inspectors wroteBased on observation and interviews, the facility failed to ensure drugs were accessible to only authorized personnel by failing to ensure a medication remained locked away when not in use by having a medication stored at a resident's bedside for 1 (#66) of 1 (#66) reviewed for medication storage.

Inspectors wroteBased on observations, record review and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (#231) of 1 resident reviewed for dignity. The facility failed to respect resident #231's request for a more textured diet.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a resident maintained acceptable parameters of nutrition by failing to provide a diabetic nutritional supplement as ordered by the physician for a resident who had a recent significant weight loss for 1 (#27) of 3 (#25, #27, #231) residents reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medication use for 1 (#74) of 5 (#16, #34, #59, #70, #74) sampled residents reviewed for unnecessary medications. The physician failed to ensure a psychotropic medication (Vistaril) was not ordered to be given as needed for a time period greater than 14 days for resident #74.

Inspectors wroteBased on record reviews and interviews, the facility failed to protect the resident's right to be free from physical abuse by a visitor for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical abuse by a visitor. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on record review and interviews the facility failed to ensure that an alleged violation involving physical abuse was reported immediately to the administrator for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse.