A list of the most recent deficiencies for Havenwood Care Center. 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-12-04 | 2023-12-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-21 | 2023-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-06 | 2023-09-28 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-05-24 | 2023-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-24 | 2023-07-21 | N |
| Keep all essential equipment working safely. | Health | 2023-05-24 | 2023-07-21 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-24 | 2023-07-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-25 | 2023-07-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-24 | 2023-07-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-25 | 2023-07-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-25 | 2023-07-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-24 | 2023-07-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-24 | 2023-07-07 | 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 | 2023-05-24 | 2023-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-24 | 2023-07-07 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-05-25 | 2023-07-07 | 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 | 2023-05-25 | 2023-07-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-25 | 2023-07-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-25 | 2023-07-05 | 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 | 2023-05-24 | 2023-06-30 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-05-24 | 2023-06-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-25 | 2023-06-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-25 | 2023-06-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-25 | 2023-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-25 | 2023-06-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-05-25 | 2023-06-29 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-05-25 | 2023-06-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-20 | 2022-08-12 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-02 | 2022-06-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-02 | 2022-06-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-22 | 2022-05-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-22 | 2022-05-11 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-23 | 2022-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-05-01 | 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 | 2022-02-25 | 2022-04-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-25 | 2022-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-25 | 2022-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-03-24 | N |
| Keep all essential equipment working safely. | Health | 2022-02-25 | 2022-03-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-25 | 2022-03-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-02-23 | 2022-03-18 | 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 | 2022-02-23 | 2022-03-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-23 | 2022-03-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-21 | 2022-01-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-21 | 2022-01-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-05 | 2021-12-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-09 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-05 | 2021-12-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-15 | 2021-11-11 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-01 | 2019-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-01 | 2019-12-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-01 | 2019-12-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-01 | 2019-12-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-01 | 2019-12-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-01 | 2019-12-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-01 | 2019-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-01 | 2019-12-17 | 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 | 2019-10-29 | 2019-11-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-29 | 2019-11-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-29 | 2019-11-14 | N |
