Haven Post Acute

Inspectors wroteBased on interviews and record review, the facility failed to ensure safe oxygen administration in accordance with its policy for one of three sampled residents (Resident 2) when Resident 2 was connected to an oxygen concentrator (a machine which delivers oxygen) labeled, broken, on June 2, 2026. This failure had the potential to cause a decline in Resident 2's respiratory status, including decreased oxygen saturation (a measurement of how much oxygen the red blood cells are carrying in the blood), shortness of breath (difficulty breathing) and lung injury, placing Resident 2's health and safety at risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records by not documenting resident-reported falls for one (1) of three (3) sampled residents (Resident 1). This failure resulted in a medical record that did not reflect Resident 1 reported change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when buildup of grime and debris were noted on the floor and walls of kitchen's walk-in refrigerator. This failure had the potential to result in accumulation of pathogenic microorganisms (germs or infectious agents that can cause disease) and attraction of insects or rodents, which could place the health and safety of 88 highly vulnerable residents who receives food from the kitchen at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure their weight change protocol was implemented for one of two residents (Resident 50) reviewed for nutrition when the Registered Dietitian Nutritionist (RDN) recommendations for Resident 50, which included weekly weights monitoring and administration of appetite stimulant (substances that increase hunger and food intake) were not carried out timely. These failures have the potential to place Resident 50 at risk for malnutrition (state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients to meet its physiological needs), increasing the risk of further weight loss, frailty, and weakened immune function, muscle wasting, weakness, reduced mobility, and cognitive and psychological decline, potentially leading to confusion, lethargy, and depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications and treatment supplies were stored in accordance with the facility's policy and procedure when: 1. Two expired Central Line Trays (a kit containing the necessary supplies for maintaining a central venous catheter [long thin tube inserted into a large vein near the heart]) were found in the intravenous cart (IV cart- mobile cart used to store intravenous supplies) and were available for use. 2. Six different types of expired dressings (pads or materials applied directly to wounds to protect them, promote healing, and absorb fluids), in various quantities were found inside the treatment cart and were available for use. 3. A medication treatment cup filled with an unidentified cream was found underneath Resident 5's bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pain Assessment and Management policy was implemented for one of two residents (Resident 214) reviewed for pain, when Resident 214's PRN (pro re nata; as needed) pain medication was not administered as ordered by the physician. This failure had the potential to put Resident 214 in unnecessary prolonged pain and discomfort and had the potential for increased suffering, delayed recovery, and reduced mobility, ultimately affecting the resident's overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate (determined by calculating the percentage of medication errors (observed or identified preparation or administration of medications or biologicals which is not in accordance with prescriber's order; manufacturer's specifications; or accepted professional standards and principles) observed during a medication administration observation) were not 5 percent or greater. There were three medication errors identified out of 33 opportunities for errors, affecting one of 8 residents (Resident 214), resulting in an overall medication error rate of 9.09 % when three of Resident 214's were not administered in accordance with prescriber's order and facility policy on March 4, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight residents (Resident 214) reviewed for medication administration was free of significant medication error (observed or identified preparation or administration of medications or biologicals which is not in accordance with prescriber's order; manufacturer's specifications (not recommendations); or accepted professional standards and principles, which causes the resident discomfort or jeopardizes his or her health and safety) when three of Resident 214's medications were not administered in accordance with physician's order and facility policy on March 4, 2025. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow its policy and procedure to provide care and services for residents and ensure call lights are answered in a timely manner for all four sampled residents (Residents 1, 2, 3, and 4). This failure has the potential to jeopardize the health and safety of clinically compromised Residents (Residents 1, 2, 3, and 4) when their requests for assistance with activities of daily living were not responded to promptly.

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision, to a resident identified as having moderate risk of elopement (risk that refers to a situation where a resident, has a moderate likelihood or possibility of leaving the premises without authorization or supervision, wandering away from a controlled environment, which can pose safety risks for the individual) for one of three sampled residents (Resident 1), when Resident 1 ' s elopement and wandering care plan did not address the specific monitoring needs and frequency necessary to minimize the risk or prevent Resident 1 leaving a safe area without the facility ' s awareness on March 6, 2024, and had not been found for more than 72 hours. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of four sampled residents (Resident 1). This failure placed Resident 1's health and safety at risk, when he developed a facility acquired sacrum (lower back/spine) pressure injury and right hip stage IV (full-thickness skin and tissue loss).

Inspectors wroteBased on interview, and record review, the facility failed to ensure that an allegation of abuse was promptly reported to the Administrator, who is the Abuse Coordinator, and the appropriate agencies in accordance with the facility's policy and procedure, for one of three residents (Resident 1). This failure had the potential for an allegation of abuse to go uninvestigated and unreported thereby increasing the chances of harm to Resident 1.

Inspectors wroteBased on observation, interview, and facility policy and procedure (P & P) review, the facility failed to ensure the food preparation sink was equipped with an air gap (backflow prevention to stop cross-connections and contamination by discharging water and waste across an unobstructed space (a gap of air) to prevent cross contamination. This failure had the potential to place 94 of 95 residents receiving meals prepared in the kitchen to foodborne illness related to cross contamination.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to: 1. Maintain temperature logs for the facility resident refrigerator, 2. Discard food items in the facility resident refrigerator by the use by date listed on each item. These failures had the potential to spread foodborne illness to residents who utilize the facility resident refrigerator.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to maintain infection control practices when: 1. One of six sampled residents (Resident 23) and two of two unsampled residents (Resident 60 and 61) had urinals in their rooms which were not labeled with room/bed number and/or resident's name. 2. Staff were observed entering Yellow Zone (residents in the Yellow Zone are considered Persons Under Investigation (PUIs) for COVID-19 (a contagious and potentially fatal respiratory virus) rooms without donning (putting on) the appropriate personal protective equipment (PPE - gown, gloves, isolation gown, face shield or goggles, and an N95 respirator (a mask that filters 95% of airborne particles). These failures had the potential to spread infectious disease to other residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity when one out of six sampled residents (Resident 94) was seen wearing only a hospital gown and had no personal clothing in their possession. This failure had a potential to cause embarrassment and limit socialization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents were safeguarded from misappropriation of property when one out of six sampled residents (Resident 312) reported the loss of $2040 from his belongings upon admission, and the facility failed to report the incident to all the agencies listed within the facility policy. This failure had the potential for further allegations of misappropriation of property from residents to occur within the facility. Findings During a concurrent observation and interview on November 1, 2021, at 9:42 AM, with a Resident, (Resident 312) he was observed to have difficulty being able to see when he was feeling for his walking cane and then stated that he was blind. He reported that $2040 was missing from his belongings when he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the smoking assessment for one of one resident (Resident 58) was completed within 14 days of admission. This deficient practice had the potential for place Resident 58 at risk for smoking related injuries by delaying accurately assessing Resident 58's safety awareness when smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a smoking care plan was completed for two of twenty-nine residents (Resident 58 and 99) within seven days of admission. This deficient practice had the potential for placing Residents 58 and 99 at risk for smoking related injuries.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to implement interdisciplinary team (IDT-a meeting of clinical staff) recommendations to prevent future falls, following a fall with major injuries for one resident, Resident 91. This failure had the potential to result in injury related to fall precautions not being implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discontinue oxygen as per physician's order for one of six sampled residents (Resident 58) when oxygen was being administered at 5 liters (a unit of measurement) via a nasal cannula (a tubing that delivers oxygen through the nose) to a resident with a diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that causes obstructed airflow from the lungs). This failure had the potential for Resident 58's to lose the drive to breath due to diagnosis of COPD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of residents when a mechanical lift and two laundry hampers were stored in front of one out of four emergency exits. This failure had the potential to cause harm and even death to residents needing to evacuate the facility in the event of a disaster such as a fire.