Loch Haven

Inspectors wroteBased on interview and record review, the facility failed to identify the root cause of an altercation involving two residents (Residents #1 and #2), who had a diagnosis of dementia, in a review of seven sampled residents, following a physical altercation on 8/12/25, failed to effectively communicate the altercation to staff, and failed to develop individualized interventions to address the root cause and to prevent further incidents. On 8/15/25, Resident #2 approached Resident #1, in the same manner he/she did on 8/12/25, and knocked Resident #1 down with his/her walker. The facility census was 73. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. Staff did not securely seal, label, date, or store food items per manufacturer's instructions. Staff did not practice proper hand and glove hygiene, hair restraint usage, and consumption of personal food items. Staff did not maintain surfaces and equipment to be free from a buildup of grease and debris and did not ensure surfaces were sanitized properly. Staff did not ensure dishes and utensils were stored and handled in a sanitary manner. The facility census was 73. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that enhanced residents' dignity and ensured full recognition of individuality for one resident (Resident #72), in a review of 18 sampled residents, and three additional residents (Residents #26, #32 and #57). The facility census was 72. Review of the facility policy, Assistance with Meals, revised March 2022, showed the following:-Residents shall receive assistance with meals in a manner that meets the individual needs of each resident;-Facility staff will serve resident trays and will help residents who require assistance with eating;-Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, - Do not stand over residents while assisting them with meals. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Residents # 27 and #72), in a review of 18 sampled residents, and one additional resident (Resident #26), were provided the right to choose schedules (including waking times) and make choices about aspects of their lives in the facility that were significant to the residents. The facility census was 72. Review of the facility policy, Quality of Life-Dignity, revised February 2020, showed the following:-Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem;-Residents are treated with dignity and respect at all times;-The facility culture is one that supports and encourages humanization and individuation of residents and honors resident choices, preferences, values and beliefs. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit a Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff) in a timely manner and in accordance with guidelines for one resident (Resident #18) in a review of 18 sampled residents and five additional residents (Resident #15, #25, #30, #32 and #36). The facility's census was 72. The facility did not provide a policy for MDS assessment and transmission upon request. Review of the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) version 3.0 Resident Assessment Instrument (RAI) User's Manual, dated October 2024, showed the following: -For all non-admission assessments, the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise the care plan for two residents (Resident #2 and Resident #72) in a review of 18 sampled residents, to reflect the resident's specific condition and/or needs. The facility census was 72. Review of the facility policy, Goals and Objectives, Care Plans, revised 2009, showed the following: -Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence; -Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: -Are resident oriented; -Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and can report whether the desired outcomes are being achieved; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure chemicals were secured in a locked storage area and not accessible to residents. The facility failed to ensure the electric range, located in the north activity room was disabled when not in use and staff were not present. The facility census was 72. 1. Review of Resident #62's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 06/17/25, showed the following: -Cognitively impaired; -Diagnosis of non-Alzheimer's dementia (a group of conditions causing cognitive decline, impacting memory, thinking and behavior, that are not due to Alzheimer's disease). Observation on 08/06/25 at 4:10 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week and failed to ensure the Director of Nursing (DON) worked as a charge nurse only when the facility had a census of 60 or less. The facility census was 72. 1. Review of the Facility Assessment, dated 07/09/25 showed the following:-Average daily census: 70;Staff included one Registered Nurse, Director of Nurses full time on days, an Assistant Director of Nursing (ADON) full time on days, and an RN or Licensed Practical Nurse (LPN), two for the day shift and one for night shift. 2. Review of the Licensed Nurse Schedule, dated January 2025, showed no hours of RN coverage for 01/01/25. Review of the Licensed Nurse Schedule, dated 01/07/25, showed no hours of RN coverage scheduled. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of each nurse aide at least once every 12 months and provide regular in-service education based upon the outcome of the reviews. The facility census was 72. The facility did not provide a policy for annual performance reviews. 1. Review of a list of current staff, dated 08/05/25 showed the following:-Certified Nurse Aide (CNA) I: Date of hire 04/15/09;-CNA J: Date of hire 07/03/23;-CNA H: Date of hire 07/04/07;-CNA B: Date of hire 10/20/22;-CNA L: Date of hire 02/10/11. Record review showed no documentation of nurse aide evaluations or annual performance reviews for CNA B, CNA H, CNA I, CNA J or CNA L. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at an appetizing temperature. The facility census was 73. Record review of the facility policy, Serving Temperatures for Hot and Cold Foods, revised 2020, showed the following: -Food will be served at the following temperatures to ensure a safe and appetizing dining experience: -Vegetables - 135 degrees Fahrenheit (F) to 170 degrees F; -Fruits, desserts, and dairy products - 41 degrees F or below; -The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal service. Food temperatures will be recorded. 1. Review of food temperature logs, located in the kitchen, for all meals (breakfast, lunch, dinner) for 8/1/25, 8/2/25, and 8/3/25 were blank. 2. Review of the Diet Orders, printed 8/4/25, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff offered a nourishing bedtime snack to two residents (Resident #6 and Resident #11) in a review of 18 sampled residents and two additional residents (Resident #25 and Resident #50) when meals were served greater than 14 hours apart. The facility census was 72. The facility did not provide a policy for frequency of meals or bedtime snacks upon request. 1. Review of the undated Meals and Memories Cafe Mealtimes, posted by the dining room, showed the following:-Breakfast: 7:30 A.M. to 8:30 A.M.;-Lunch: 11:30 A.M. to 12:30 P.M.;-Supper: 4:30 P.M. to 5:30 P.M. (14 hours between the supper and breakfast meals). 2. Observation and interview of the facility resident council meeting on 08/05/25 at 11:00 A.M. showed the following: -Ten residents attended the meeting; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene in accordance with acceptable standards of practice to prevent the spread of infection for three residents (Residents #3, #40 and #45). The facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP), as required by facility policy, when repositioning to one resident (Resident #6), who had a pressure ulcer with infection. The facility failed to ensure catheter drainage bags and tubing were kept off the floor to prevent risk of contamination for two residents (Residents #3 and #72), and failed to ensure nebulizer and bilevel positive airway pressure (BiPAP; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide all staff with written documentation of education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine and failed to maintain documentation related to staff COVID-19 vaccination status. The facility census was 72. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required in-service training for nurse aides that included dementia management training as part of the required minimum 12 hours of training per year. The facility census was 72. 1. Review of the Facility Assessment, dated 07/09/25, showed the following:-Staff training/education and competencies:-New hire training for nursing staff includes:-Dementia Care: Managing Challenging Behaviors;-Annual Education includes all the new hire training topics plus Corporate Compliance: The Basics for all staff, Overview of the Aging Process and Pressure Ulcer Prevention for all clinical staff. 2. Review of a list of current facility staff, dated 08/05/25, showed the following:-Certified Nurse Aide (CNA) I date of hire: 04/15/09;-CNA/Certified Medication Technician (CMT) C: date of hire 07/19/14;-CNA K date of hire: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served meals to meet the nutritional needs of the residents when staff failed to prepare and serve food according to the physician's orders and spreadsheet menu. The facility census was 72. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 07/27/25, showed the following:-Severe cognitive impairment;-Diagnoses included vitamin deficiency, -Dependent on staff for eating;-Mechanically altered diet such as pureed food. Review of the resident's Care Plan, revised 02/24/25, showed the following:-The resident receives regular pureed diet;-Staff will need to feed the resident; -Monitor and record percentage of food intake. Review of the resident's Physician Orders dated 03/27/25, showed diet pureed texture, double portions with meals every day. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their antibiotic stewardship policy and consistently track infections and antibiotic use for one resident (Resident #3) in a review of 18 sampled residents. The facility census was 72. Review of the facility's undated policy, Antibiotic Stewardship, showed the following:-The facility will record all antibiotics used in the facility on a resident-to-resident basis (dose, duration, indication);-The facility will alert the attending physician when antibiotics have reached 14 days and obtain new orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff notified the resident and/or the resident's representative in writing of a transfer to a hospital and failed to provide the bed hold policy at the time of transfer to four residents (Resident #3, #10, #74 and #78) or the resident representatives, in a sample of four residents reviewed related to discharge or transfer. The facility census was 72. Review of the undated document, Bed Hold Statement and Notice of Emergency Transfers, showed the following:-The facility established and maintains policies and procedures regarding transfer, discharge, and provision of services for all individuals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #2), in a review of seven sampled residents, received the necessary care and services in accordance with professional standards of practice when the facility failed to assess and report Resident #2's complaint of right eye pain, redness, watering, and blurry and dim vision timely. The resident was involved in a physical altercation with Resident #1 on 02/10/25, where both resided on the facility's Special Care Unit (SCU - dementia care unit). Resident #2 reported to family and staff in the days following that his/her eye hurt. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor one resident's (Resident #1's) monitoring device (a small wristwatch-sized device (Tag) worn by a resident or attached to an asset (wheelchair, walker) that will trigger an alarm if in close proximity of an activation field; usually an exit door), per the manufacturer's instructions to ensure it functioned appropriately and would alert staff if the resident attempted to leave the facility without staff knowledge, in a review of 14 sampled residents. The resident was assessed as at risk for elopement and utilized a monitoring device as an intervention to address that risk. On 3/2/24 at 7:24 A.M., the resident exited the facility through the main entrance without staff knowledge in his/her motorized wheelchair. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that food was stored and served according to professional food safety standards. Specifically, the facility failed to date opened food items stored in the reach-in cooler and failed to ensure staff used appropriate hand hygiene and glove use when handling ready-to-eat foods.

Inspectors wroteBased on document review and interviews, the facility failed to complete a Minimum Data Set (MDS) at least quarterly for 6 residents (Residents #11, #20, #27, #43, #46, and #50) of 27 sampled residents reviewed for resident assessments.

Inspectors wroteBased on observations, interviews, record reviews, and facility document review, the facility failed to ensure a medication error rate of less than 5%. The facility's medication error rate was 14.8%, resulting from 4 errors out of 27 opportunities.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1 (Resident #36) of 1 resident reviewed for self-administration of medications had been assessed to determine if it was safe for the resident to self-administer an albuterol nebulizer treatment.

Inspectors wroteBased on record review, interviews, facility document review, and review of a Food and Drug Administration (FDA) medication guide, the facility's pharmacy consultant failed to identify and report an irregularity related to the use of a PRN [pro re nata; as needed] antianxiety medication for 1 (Resident #48) of 5 residents reviewed for unnecessary medications. Specifically, the pharmacy consultant failed to identify an order for the use of a PRN antianxiety medication that extended beyond 14 days without a specific duration for the use documented by the resident's physician.

Inspectors wroteBased on observations, interviews, record review, and review of a blood glucose meter manufacturer's instruction manual, the facility failed to ensure a blood glucose meter was disinfected after use. Specifically, a blood glucose meter was not disinfected after it was used to conduct a finger stick blood glucose test for 1 (Resident #207) of 2 residents who used blood glucose meters stored in the Hall 300/400 treatment cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled, dated or discarded when expired; failed to ensure ceiling air vents and equipment were clean and free of an accumulation of debris; failed to ensure the dish machine vent was clean and free of a buildup of debris; failed to maintain fan shrouds inside the walk-in cooler to free of an accumulation of debris; failed to ensure pans were not stacked and stored wet; and failed to ensure trash cans were covered when not in use. The facility census was 88. 1. Review of the facility policy, Food Storage, dated 2010, showed the following: -All containers must be legible and accurately labeled; -Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within three days or discarded. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure housekeeping and/or maintenance services were provided to ensure the ceiling vents were clean and good repair. The facility failed to maintain wheelchairs in good repair for four residents (Residents #24, #48, #54 and #81). The facility census was 88. 1. Review of the facility policy Housekeeping and Maintenance Services, dated 5/15/06, showed the following: -Maintain the facility in a manner that enhanced residents ability to engage in daily activities of their choice; -Maintain a safe, comfortable, sanitary, and orderly interior; -Assuresthe environmentt was free of hazards that might contribute to injury or disease; -Provide preventive routine cleaning and maintenance of the room floors, fixtures, windows and furnishings heating and air systems and resident care equipment. 2. Observation on 01/14/20 between 9:03 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foot pedals were in place on wheelchairs during transportation for one resident (Resident #65), in a review of 18 sampled residents and four additional residents, (Resident #46, #60, # 77, and #91). The facility census was 88. During interview on 1/16/20 at 11:35 A.M. the administrator said the facility did not have a policy regarding use of wheelchair foot rests. 1. Review of Resident #91's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/19,showed the following: -Diagnosis of Alzheimer's disease -Cognition severely impaired; -Extensive assistance required for transfers; -Walking did not occur; -Totally dependent on staff for wheelchair locomotion; -Devices: wheelchair. Review of resident's care plan updated 2/22/19, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess, obtain informed consents, and reassess the safety and effectiveness of cane rail use for three residents (Resident #52, #84, and #85) of 18 sampled residents and five additional residents (Resident # 9, # 50, #60, #65, and #77) who had cane rails in place on their beds. The facility census was 88. Review of the facility's Restraint Policy (Device Decision Policy) undated, showed the following: -Assessment: Before any device can be used the Device Decision Guide must be completed to determine if the device is a restraint, enabler, or safety hazard; -Monitoring: Make observations following the implementation of a device; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to destroy expired medications stored in the medication rooms. The facility also failed to ensure adequate temperature control for the storage of medication in the west wingmedication roomm. Thee facility census was 88. Review of the facility undated policy Disposal of Discontinued and/or Unused Medication showed the following: -All medications to be disposed of must be counted by the pharmacist and licensed nurse or two licensed nurses and record on the drug destruction record; -Any medication that can be returned to the pharmacies would be returned within 30 days; -Medication that could not be returned would be destroyed on the premises within 30 days using a method approved by the US Food and Drug Administration. 1. Observation of Oakview Cottage Medication room on 01/15/20 at 05:05 PM showed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff washed their hands and changed soiled gloves after each direct resident contact and where indicated by professional standards of practice during personal care for two additional residents (Resident #4 and #193). The facility failed to disinfect a bedside table used for treatment according to acceptable infection control practice for one sampled resident (Resident #5) in a review of 18 residents. The facility census was 88. During interview on 1/16/20 at 11:35 A.M. the administrator said the facility did not have a policy regarding providing Activity of Daily Living (ADL) cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the Nurse Assistant in a Long-Term Care Facility manual, 2001 revision, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided two additional residents (Resident #193, and #4) that were unable to do their own Activities of Daily Living (ADL's), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 88. During interview on 1/16/20 at 11:35 A.M. the administrator said the facility did not have a policy regarding providing ADL cares. Staff should follow the Certified Nurse Assistant (CNA) manual. Review of the Nurse Assistant In A Long Term Care Facility manual revision 2001, showed the following: For oral hygiene: -Purposes: [...]