Deficiency Records for Kith Haven

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Updated as of March 01, 2024

A list of the most recent deficiencies for Kith Haven. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-12-13 2023-01-10 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-12-13 2023-01-10 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-12-13 2023-01-10 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-12-13 2023-01-10 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-12-13 2023-01-10 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-12-13 2023-01-10 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-12-13 2023-01-10 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-12-13 2023-01-10 N
Post nurse staffing information every day. Health 2022-12-13 2023-01-10 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-12-13 2023-01-10 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-12-13 2023-01-10 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-12-13 2023-01-10 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2022-12-13 2023-01-10 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-12-13 2023-01-10 N
Provide and implement an infection prevention and control program. Health 2022-12-13 2023-01-10 N
Implement a program that monitors antibiotic use. Health 2022-12-13 2023-01-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-07 2023-01-10 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-12-07 2023-01-10 N
Have restrictions on the use of portable space heaters. Fire Safety 2022-12-07 2023-01-10 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-11-07 2022-12-29 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2022-11-07 2022-12-29 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-11-07 2022-12-29 Y
Respond appropriately to all alleged violations. Health 2022-11-07 2022-12-29 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-07 2022-12-29 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-11-07 2022-12-29 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2022-11-07 2022-12-29 Y
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-11-07 2022-12-29 Y
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2022-11-07 2022-12-29 Y
Ensure that residents are free from significant medication errors. Health 2022-11-07 2022-12-29 Y
Provide and implement an infection prevention and control program. Health 2022-11-07 2022-12-29 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-08-30 2022-09-29 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2022-08-30 2022-09-29 N
Ensure staff are vaccinated for COVID-19 Health 2022-08-30 2022-09-29 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-18 2022-09-29 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-21 2022-06-02 Y
Provide activities to meet all resident's needs. Health 2021-10-12 2021-11-10 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-10-12 2021-11-10 Y
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2021-10-12 2021-11-10 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-09-03 2021-09-28 N
Provide for the safe, appropriate administration of IV fluids for a resident when needed. Health 2021-09-03 2021-09-28 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-09-03 2021-09-28 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-09-03 2021-09-28 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2021-08-26 2021-09-28 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-08-26 2021-09-28 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2021-08-26 2021-09-28 Y
Have properly located and lighted "Exit" signs. Fire Safety 2021-09-08 2021-09-28 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2021-09-08 2021-09-28 N
Install an approved automatic sprinkler system. Fire Safety 2021-09-08 2021-09-28 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-09-08 2021-09-28 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-09-08 2021-09-28 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-03-17 2021-04-14 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-10-17 2019-11-19 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2019-10-17 2019-11-19 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-10-17 2019-11-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-10-17 2019-11-19 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-10-17 2019-11-19 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2019-10-17 2019-11-19 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2019-10-17 2019-11-19 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2019-10-17 2019-11-19 N
Provide or obtain dental services for each resident. Health 2019-10-17 2019-11-19 N
Provide and implement an infection prevention and control program. Health 2019-10-17 2019-11-19 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2019-10-16 2019-11-19 N
Provide properly protected cooking facilities. Fire Safety 2019-10-16 2019-11-19 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-10-16 2019-11-19 N
Have restrictions on the use of highly flammable decorations. Fire Safety 2019-10-16 2019-11-19 N