Resthaven Living Center

Inspectors wroteBased on record reviews and interviews, the facility failed to inform the resident's responsible party (RP) of a resident's change in condition for 1 (#1) of 3 sampled residents. The facility failed to notify Resident #1's RP when Resident #1 was transferred to the hospital. Review of the facility's policy titled Change in a Resident's Condition or Status with a revision date of May 2017, revealed the following, in part:Policy StatementOur facility shall promptly notify the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when:b. There is a significant change in the resident's physical, mental, or psychosocial status; e. It is necessary to transfer the resident to a hospital. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5% by failing to give medications as ordered for 2 (#67 and #85) of 5 residents observed during medication administration. A total of 25 opportunities were observed with 3 medication errors, which resulted in a medication error rate of 12.00%.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure:1. The ice machine was maintained in safe operating and sanitary condition; and2. Pots and pans were sanitized. This deficient practice had the potential to affect all 81 residents who ate from the kitchen.

Inspectors wroteBased on observation and interviews, the facility failed to ensure refuse containers were in good condition and waste was properly contained. This deficient practice had the potential to affect 82 residents residing in the facility.

Inspectors wroteBased on observations and interviews the facility failed to ensure a safe, sanitary and comfortable environment. The facility failed to ensure the residents' Shower Room A was comfortable and sanitary.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (#2 and #51) of 22 residents reviewed for accommodation of needs. Review of the facility's policy, Resident Call Light System, revised 06/2023, revealed the following, in part:Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guideline: 4. Ensure that the call light is easily reachable by the resident. Resident #2Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Bilateral Primary Osteoarthritis of Hip, Mild Neurocognitive Disorder with Behavioral Disturbance, Wedge Compression Fracture of T9-T10 Vertebra, Intellectual Disabilities, Schizophrenia, and Cerebral Infarction. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#92) of 3 residents reviewed for closed records. Review of Resident #92's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/10/2025 revealed Resident #92 was discharged to a Short-Term General Hospital. Review of Resident #92's Nurse's Notes revealed the following, in part:12/10/2025 at 11:20 a.m. Resident #92 left facility via wheelchair accompanied by his own transportation. On 01/14/2026 at 5:00 p.m., an interview was conducted with S9MDS. S9MDS confirmed Resident #92 left the facility against medical advice. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening Resident Review (PASRR) Level II evaluation with accurate mental health diagnoses for 1 (#67) of 2 sampled residents' records reviewed for PASRR.Review of Resident #67's Clinical Record revealed Resident #67 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Bipolar Disorder, Depression, and Anxiety Disorder. Review of Resident #67's PASRR Level 1 Form dated 07/30/2025 revealed mental health diagnoses which included Major Depression and Anxiety Disorder. Further review revealed Bipolar Disorder diagnosis was not listed. An interview was conducted on 01/14/2026 at 5:25 p.m. with S10LPNADM. S10LPNADM stated she completed Resident #67's PASRR Level 1 Form, dated 07/30/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#95) of 3 residents reviewed for infection control. The facility failed to ensure staff wore proper PPE while providing direct care to Resident #95, who was on Enhanced Barrier Precautions.

Inspectors wroteBased on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 84 residents who consumed food from the kitchen.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 84 residents who were served meals from the kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#19) of 19 sampled residents reviewed for MDS.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to provide residents necessary respiratory care and services in accordance with accepted professional standards of practice for 1 (#3) of 1 (#3) resident reviewed for respiratory services. The facility failed to change Resident #3's oxygen tubing and humidifier bottle out weekly.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 2 (#3 and #290) of 19 residents reviewed in the final sample.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#23) of 5 (#2, #23, #55, #57, and #85) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing direct care for a resident who was on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the results of the most recent annual survey and complaint surveys were available for resident review.

Inspectors wroteBased on observation and interviews, the facility failed to ensure current nurse staffing data was posted daily. This deficient practice had the potential to affect any of the 85 residents residing in the facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure services were provided to meet quality professional standards for 2 (#1 and #3) of 3 (#1, #2, and #3) residents reviewed for falls. The facility failed to ensure staff documented neurological assessments after unwitnessed falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 1 (#3) of 3 (#1, #2, and #3) residents reviewed for unnecessary psychotropic medications. The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days and indicated the duration for the PRN order for Resident #3.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status for 1 (#4) of 4 (#1, #2, #3, and #4) residents reviewed for MDS.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#3) of 4 (#1, #2, #3, and #4) residents reviewed. The facility failed to ensure S10LPN documented administered narcotic medications on Resident #3's Medication Administration Record.

Inspectors wroteBased on interviews and record review, the facility failed to designate a member of the facility's interdisciplinary team to be responsible for working with hospice representatives to coordinate care as evidence by the facility failing to ensure hospice binders were up to date for 1(#3) of 1(#3) resident reviewed for hospice care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#12) of 3 (#12, #53, and #76) residents reviewed for ADLs.

Inspectors wroteBased on interviews and record review, the facility failed to electronically submit accurate payroll information for direct care staffing as required.