Kith Haven

Inspectors wroteThis citation pertains to intake Number 3033712. Based on interview and record review, the facility failed to ensure that 3 residents (Resident #102, Resident #103 and Resident #104) had behavioral interventions and residents' responses to interventions documented for 3 residents reviewed for behaviors. Findings Include:Resident #102: Review of the Face Sheet, Nursing notes dated 7/26, and care plans dated 12/23, revealed Resident #102 was [AGE] years old, alert with confusion, admitted to the facility on [DATE], and dependent on staff for Activities of Daily Living (ADL). The residents diagnoses included stroke with hemiplegia and hemiparesis of the right side, anxiety, adjustment disorder, major depression, mild intellectual disabilities and Asperger's syndrome with behaviors. [...]

Inspectors wroteThis Citation Pertains to Intake# 2985732Based on observation, interview and record review, the facility failed to protect the resident's (Resident #101) right to be free from abuse by Resident #102 of 3 residents reviewed for abuse, resulting in resident #101 needing hospital treatment for assault, facial contusion and closed head injury. Findings Include:Review of Resident #101's medical record revealed Resident #101 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of a stroke, Dementia, diabetes, history of seizures, cognitive communication deficit, anxiety, and hypertension. The MDS assessment dated [DATE] revealed the resident had moderate cognitive decline with a Brief Interview for Mental Status/BIMS score of 8/15 and needed some assistance with care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen and proper cold holding during meal service, resulting in the potential to spread foodborne illness to all residents who consume food from the kitchen. Findings Include:On 3/17/2026 at 12:10 PM, tour of the kitchen was completed with CDM (Certified Dietary Manager) D, and following was observed:Ice Machine:Bin seal/trim was partway detached from the bottom lip of the bin. Inside white flap had orange colored residue spanning the length of it. The inside of the ice bin is blue in color but was peeling and was a white/translucent color. CDM D stated a contracted company empties and cleans the ice machine every 3 months. The bottom of the dolly cart with approximately 35 clean mugs stacked upon it was soiled with debris and other unknown food particles. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interdisciplinary review and revision of comprehensive care plans for one resident (Resident #65) of two residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for six dependent residents (R11, R15, R31, R50, R65, R122) of eight reviewed resulting in unkempt hair, facial hair on female residents, Resident #122 was soaked in urine for hours, unshaven male residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide enteral tube care per professional standards of practice for four residents (R50, R65, R81, R115) of four residents reviewed.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were 1) consistently assessed for Influenza and Pneumococcal vaccinations on admission, per Standards of Practice; 2) provided an educational vaccination information sheet for each vaccination, 3) and document vaccination information in the residents' medical record, including consent or declination of the vaccinations, which could potentially effect all residents, including Residents (#5, #15, #61, and #74) reviewed for vaccinations, resulting in the potential for exposure to Influenza and Pneumococcal disease, and severe illness. Findings Include: CDC/Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report (MMWR), Prevention and Control of Seasonal Influenza with Vaccines: [...]

Inspectors wroteBased on interview and record review the facility failed to specify indication for usage and provide a clinical rationale for duplicate therapy of antipsychotic medication for one resident (Resident #88) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of a significant change Minimum Data Set (MDS) assessment for one resident (Resident #65) of one resident reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to ensure that communication was completed in an understandable language including availability of adaptive equipment and translation devices for one resident (Resident #88) of one resident reviewed, resulting in lack of implementation of planned interventions for communication with a resident who does not speak English.

Inspectors wroteBased on observation, interview and record review, the facility 1) failed to ensure that skin was assessed and monitored beneath a soft helmet for 1 resident (Resident #81) of 6 residents reviewed for skin care; and 2) Ensure that a resident received peak and through (max/min concentration of drug in bloodstream monitoring to maintain therapeutic medication levels by not obtaining timely laboratory testing for vancomycin antibiotic therapy for one resident (Resident #139) of one resident reviewed for IV therapy, resulting in the potential for sub therapeutic care and prolonged therapy. Findings Include:Resident #139 (R139): According to a review of R139's medical record, the resident was admitted to the facility on [DATE] for skilled nursing care related to diagnoses including: chronic heart failure, Fracture of vertebrae (back), infection following surgical procedure; [...]

Inspectors wroteBased on observation, interview and recorded review, the facility failed to ensure that one resident's (Resident #104) Behavior Care Plan, dated 01/14/25, had interventions which were implemented consistently for Resident #104, who had a history of poor impulse control and aggression, of 4 residents reviewed. Findings Include: Resident #104:Review of Face Sheet, care plans dated 1/2025, nursing progress notes dated 1/7/26 and 1/8/26, revealed Resident #104 was [AGE] years old, alert and able to make own decisions, admitted to the facility on [DATE], required staff to assist with Activities of Daily Living, had a below knee left leg amputation, was wheelchair bound, and received dialysis treatments. [...]

Inspectors wroteThis Citation Pertains to Intake Numbers: 2575687, 2577971, and 2580349. Based on interview and record review, the facility failed to develop and implement policies and procedures to ensure effective and appropriate communication and documentation for transfer to the hospital and failed to ensure readmission to the facility for one (#701) of three Residents reviewed for discharge rights and planning.

Inspectors wroteThis citation pertains to intakes MI00153289 and MI00153294. Based on interview and record review, the facility failed to provide supervision for three residents (R5, R6, R7) of three residents reviewed for supervision, resulting in multiple resident to resident altercations.

Inspectors wroteThis Citation pertains to Intake Number MI00149971. Based on observation, interview and record review, the facility failed to address hospital discharge recommendations for blood glucose monitoring and insulin administration and follow parameters for insulin administration for two residents (Residents #1 and Resident #3) of three residents reviewed for glucose monitoring.

Inspectors wroteThis Citation pertains to Intake Number MI00151298. Based on interview and record review the facility failed to update care plans and implement interventions to prevent falls for one resident (Resident #2) of three residents reviewed for incidents and accidents, resulting in repeated falls.

Inspectors wroteBased on observation and interview the facility failed to maintain sanitary conditions in the kitchen, resulting in an increased potential for cross contamination of food, foodborne illness and improper kitchen sanitization, potentially affecting all residents who consume meals from the kitchen. Findings Include: On 1/29/2025 at approximately 10:00 AM, a tour of the kitchen was started with Assistant Administrator Q and concluded with Dietary Manager AA upon entering the kitchen, dietary staff were actively cleaning out the walk-in cooler. The following expired and/or unsanitary conditions were observed during the tour: Walk-in Cooler: -Floors had spills in different areas of what appeared to milk, and the floor was sticky in some areas. -There were miscellaneous items strewn across the floors such as lids and onion peelings. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00149049. Based on observation, interview and record review, the facility failed to ensure that residents' rights/dignity was maintained for Resident #'s 6, 38, 60, 81, 82, 94, 97 and 127, of a sample of 26 reviewed for residents' rights, dignity and ADL (activities of daily living) care, and two residents in room [ROOM NUMBER], resulting in long call light wait times, Resident complaints of food served at an unpalatable temperature, menu not followed, lack of assistance with dressing, lack of ADL care, long and jagged fingernails, complaints of staff rudeness with Resident interaction and the potential of unmet care needs, weight loss and dissatisfaction with care, services and meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that two Residents (#21, #83) received consistent pre and post dialysis weights, and failed to ensure that two Residents (#22, #107) received medications post dialysis when the residents returned to the facility from dialysis, resulting in the potential for decline in condition, lack of medication therapy, and prolonged health issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pharmacist medication regime reviews (MRR) were reviewed, acted upon and addressed in the residents' clinical record for five (#27, 40, 42, 86, 102) of five residents reviewed for MRR. resulting in medications not being adjusted with physician response to accept or decline the pharmacy recommendations. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 PM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. On 1/30/2025 at approximately 4:00 PM, a review was conducted of Resident #27's monthly pharmacy recommendations from May 2025 to December 2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications were appropriately stored in 3 of 3 Medication carts, and an unlocked treatment cart, resulting in a opened and unsecured treatment cart, opened and undated medications, lack of appropriate storage with loose tablets noted in carts, of temperature sensitive medications with irregular refrigerator temperature monitoring, and the potential for residents to receive medications with altered efficiency and potency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Infection Prevention and Control standards of practice were followed for 1). Safe handling of ice and 2). Proper storage of personal items to prevent contamination, resulting in the potential for spread of infection, which could cause serious illness. Findings Include: FACILITY Infection Control On 1/31/2025 at 1:10 PM an Activity Aide entered the facility elevator carrying 2 large basins stacked on top of each other; each basin was filled with ice. Neither basin was covered, and the ice was open to the air with the aide's body leaning against the basins. The aide was asked what was in the basins and she stated, It's ice for daquiris. The aide exited the elevator and walked in to the resident activity area. [...]

Inspectors wroteThis Citation Pertains to Intake Number MI00149049. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that resident rooms were clean, uncluttered, and in good repair for 3 Resident's #30, #39, #115 including two resident rooms (103 and 119) , resulting in an unclean physical environment. FACILITY Environment: On 1/29/2025 at 10:48 AM, room [ROOM NUMBER]'s bathroom was observed to be very soiled. The white toilet seat had many smears of brown dirt on it and the floor was covered in discolored brown stains near the toilet. Resident #39 was asked if he used his bathroom and he said he did; he said he tried to provide his own care, as much as he could. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise care plans for 2 Residents (#39, #64) of 3 residents reviewed, including Resident #39 with a swallowing deficit, and Resident #64 who had weight loss and a change in condition, resulting in the likelihood for missed interventions in treatment and unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed to 1. Ensure care was provided for a resident with a Life Vest Resident #115, and 2. Ensure wound care was ordered and completed timely for Resident #383 of two residents reviewed for standards of practice. Findings Include: Resident #383: 01/30/25 around 12:15 PM, Resident #383 was observed in the dining area with other residents enjoying his lunch. A bandage was observed spanding the length of his left forearm that was dated 1/27- at 2130 with the initials SS. When the resident was queried on what happened to his arm, he stated it occurred while he was jumping a fence. Review was completed of this TAR (Treatment Administration Record) and there were no current orders specifically for his left arm. The order that was initiated for his left rear forearm was discontinued on 1/27/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a facility-acquired pressure ulcer/skin injury for one resident (Resident #64) of 5 residents reviewed for pressure/skin issues, resulting in Resident #64 developing two new facility-acquired pressure ulcers/skin injuries as a result of poor nutritional intake including a low protein diet and and also resulting in weight loss while residing in the facility.

Inspectors wroteThis Citation pertains to Intake Number MI00149049. Based on observation, interview and record review, the facility failed to implement a restorative therapy program and develop a plan of care for restorative therapy for one Resident #97 of one reviewed for rehab and restorative therapy, resulting in the potential for functional decline, reduction in range of motion, diminished mobility and decreased independence.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent weight loss for 1 resident (Resident #64) of 7 residents reviewed for nutrition, resulting in Resident #64 having a 5.6% weight loss, low protein diet with development of pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure oxygen was provided as ordered for one resident (Resident #79) of 3 residents reviewed for respiratory care, resulting in the potential for inappropriate treatment with potential for adverse reactions .

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure suicide precautions were ordered, for one Resident #32 of one resident reviewed for mood and behavior, resulting in the potential for a lack of continuity of care and an adverse outcome for Resident #32. Findings Include: Resident #32: Behavioral-Emotional On 1/29/2025 at 10:34 AM, Resident #32 was observed lying in bed. When asked where her call light was, she said the staff took it and gave her a bell to ring. A small bell was observed on the bedside table. When asked why they gave her the bell, she said she didn't know. On 1/29/2025 at 10:39 AM, Nurse Aide L was asked why Resident #32 did not have a call light and she said the resident was on suicide watch as of that morning 1/29/2025. She said a nurse took her call light so she did not have any long cords to hurt herself and gave her a bell. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for three (#27, #90 and #102) of five residents reviewed for unnecessary medications. Findings Include: Resident #27 On 1/29/2025 at approximately 2:15 AM, a review was conducted of Resident #27's medical record and it indicated the resident admitted to the facility on [DATE] with diagnoses that included Alzheimer's, Adjustment Disorder, Delusional Disorder, Dementia, Adjustment Disorder and Major Depressive Disorder. Further review yielded the following: Physician's Orders: Risperidone Tablet 0.25 MG (milligram)- give one table by month two times a day for psychotic disorder with delusion due to known psychological. Ordered on 10/17/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow standards of practice and physician orders of parameters for blood pressure (BP) and heart rate (HR) when administering medication to one resident (Resident #22), of six residents reviewed for medication regimen review, resulting in the potential for adverse medication reactions, bradycardia (low heart rate), and re-hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely dental services were provided and communicate with dental services regarding the need for dental x-rays for one resident (Resident #97), of one resident reviewed for dental services, resulting in a broken tooth not repaired/extracted, pain, infection and the Resident's lack of knowledge of the plan of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adaptive equipment was provided for meals and hydration for one resident (Resident #14), of one resident reviewed for adaptive equipment during meals, resulting in frustration with attempting to feed self, spilling water from Styrofoam cup and the potential for weight loss and dehydration.

Inspectors wroteThis Citation Pertains to Intake Number MI00138869. Based on interview and record review, the facility failed to ensure adequate supervision to prevent physical abuse and ensure appropriate reporting and comprehensive investigations of abuse allegations for one resident (Resident #76) of two residents reviewed. This deficient practice resulted in Resident #76 suffering three separate incidents of physical abuse perpetrated by two separate residents (Resident #71 and Resident #376), the need for emergency medical treatment, and the likelihood for psychosocial distress utilizing the reasonable person concept.

Inspectors wroteThis Citation pertains to Intake Numbers MI00138258 and MI00140571. Based on observation, interview and record review, the facility failed to assess and implement interventions to prevent the development and/or worsening of pressure ulcers and ensure accurate documentation of wounds for two residents (Resident #97 and Resident #222) of four residents reviewed for pressure ulcers, resulting in the development of Stage II pressure ulcers on the buttock for Resident #97, the development of Stage II pressure ulcer to Resident #222's coccyx area and heel, pain, and overall deterioration in health status and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) ensure assistance with obtaining an appointment to fix broken eye glasses for Resident #3; 2.) ensure call lights were accessible for Residents #2, 25, 48, 70, 72, 80, 97, 107, 117, and 118; and 3.) ensure menus met resident preferences for Resident #73 and a Confidential group of Residents, resulting in impaired vision, frustration, unmet care needs, and unpalatable food.

Inspectors wroteThis Citation Pertains to Intake MI00138079. Based on observation, interview and record review, the facility failed to ensure linens were sufficiently available and in good condition for Residents #40, 75, 117 and 375, of 13 reviewed for safe, clean and homelike environment, resulting in a potential for contamination and illness, embarrassment and dissatisfaction with their living conditions. This deficient practice had the potential to affect Residents residing in the facility with a census of 115.

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans with resident changes, to ensure interventions necessary for care and services were provided for 3 residents (#'s 23, 67, 95) of 34 reviewed, resulting in the potential for unmet care needs. Findings Include. Resident #23 Accidents A review of the Face sheet and Minimum Data Set (MDS) assessment indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, with left side weakness, hypertension, history of seizures, diabetes, depression, dementia, end stage kidney disease, received dialysis, difficulty talking, feeding tube, and difficulty swallowing. [...]

Inspectors wroteThis citation pertains to Intake #MI00134673, MI00134692, MI00136760, and MI00133158. Based on observation, interview and record review, the facility failed to provide activities of daily living (ADL) care for Residents dependent on assistance from staff to provide care for Residents # 3, 23, 25, 36, 59, 67, 95, and 375 of 14 reviewed for ADL care, resulting in a lack of bathing, nail care, shaving, hair care and dressing, with the potential for body odor, infection, embarrassment, and lack of self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) properly dispose of expired medication and medical supplies; 2.) properly label medication containers; 3.) sign out narcotic medication timely; and 4.) properly secure medication carts for four of five medication and treatments carts and 3 of 3 medication rooms reviewed for medication storage and labeling, resulting in the potential for administration of expired medications with decreased efficacy, medical procedures and treatments performed with expired medical equipment/treatments and medication diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve, store, and prepare food under sanitary conditions in the facility kitchen, resulting in the increased potential for foodborne illness. This deficient practice had the potential to affect all residents who ate meals prepared by the facility out of a census of 115 residents residing in the facility.

Inspectors wroteThis citation pertains to Intake #MI00133396. Based on observation, interview and record review, the facility failed to follow evidence-based practices for Infection Control, including Transmission Based Precautions to prevent the spread of the Covid-19 virus. The failure to maintain infection control practices resulted in a likelihood for a serious adverse outcome including the spread of infectious illness. Findings Include: FACILITY Infection Control CDC: Centers for Disease Control and Prevention: Isolation and Precautions for People with Covid-19, updated May 11, 2023, If you have COVID-19, you can spread the virus to others. There are precautions you can take to prevent spreading it to others: isolation, masking and avoiding contact with people who are at high risk of getting very sick. [...]

Inspectors wroteThis Citation Pertains to Intake MI00138079. Based on observation, interview and record review, the facility failed to ensure dignified treatment during dining and ensure the provision of Resident rights for two Residents (#71 and 228), of a sample of 24, resulting in potential feelings of embarrassment, decreased self-worth, lack of knowledge of Resident rights and to act upon deprivation of rights.

Inspectors wroteThis Citation pertains to Intake Numbers MI00133967, MI00135210 and MI00140848. Based on the interview and record review, the facility failed to allow the resident's family to visit the facility regularly per resident legal representative's preference for one resident (Resident #43) of two sampled residents reviewed for visitation rights in a total of 24 sampled residents resulting in feelings of sadness, loneliness, isolation from a relative and lack of socialization.

Inspectors wroteThis Citation pertains to Intake Number MI00134673. Based on interview and record review, the facility failed to implement and operationalize timely assessment, care, and transfer following a change in condition for one resident (Resident #76) of one resident reviewed resulting in a delay in transfer and care following feeding tube dislodgment, delayed provision of nutrition/hydration, and medications, untreated pain, and the likelihood for gastrostomy (surgically created opening in the abdominal wall to the stomach for the introduction of nutrition- commonly called a PEG or G-tube) malfunction.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions were enacted to prevent a fall and assess the resident post fall for neurological changes for one Resident (#30), of five reviewed for accident hazards/falls, resulting in Resident #30 having a multiple falls, hospitalization, dislocation and fracture to the left arm, pain, decreased mobility and the lack of assessment of potential change in mental status to go undetected and untreated.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly label the enteral nutritional solution (nutrition provided by means of surgically placed percutaneous endoscopic gastrostomy tube-PEG tube) and infusion tubing set for one Residents (#118), of three reviewed for tube feeding, resulting in the potential for food borne illness from ingesting contaminated enteral feeding solution.

Inspectors wroteBased on interviews and record review, the facility failed to post an accurate documentation of the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift resulting in the potential for required information not accurately reported to the facility residents, family and the public.