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 | 2024-02-07 | 2024-03-14 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-07 | 2024-03-14 | N |
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2024-02-07 | 2024-03-14 | 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 | 2024-02-07 | 2024-03-14 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-07 | 2024-03-14 | 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 | 2024-02-07 | 2024-03-14 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-07 | 2024-03-14 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-07 | 2024-03-14 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-07 | 2024-03-14 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-07 | 2024-03-14 | 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 | 2024-02-07 | 2024-03-14 | N |
Post nurse staffing information every day. | Health | 2024-02-07 | 2024-03-14 | 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 | 2024-02-07 | 2024-03-14 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-07 | 2024-03-14 | N |
Provide and implement an infection prevention and control program. | Health | 2024-02-07 | 2024-03-14 | 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 | 2024-01-31 | 2024-03-14 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-31 | 2024-03-14 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-31 | 2024-03-14 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-31 | 2024-03-14 | N |
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 |
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 |
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 |
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 |