Deficiency Records for Havencare Nursing and Rehabilitation Center LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Havencare Nursing and Rehabilitation Center LLC. 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? |
|---|---|---|---|---|
| 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 | 2023-07-25 | 2023-08-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-14 | 2023-07-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-14 | 2023-07-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-14 | 2023-07-25 | N |
| 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 | 2023-06-14 | 2023-07-25 | 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 | 2023-06-14 | 2023-07-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-14 | 2023-07-25 | 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 | 2023-06-14 | 2023-07-25 | 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 | 2023-06-14 | 2023-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-14 | 2023-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-14 | 2023-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-05 | 2022-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-05 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-05 | 2022-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-05 | 2022-06-02 | 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 | 2022-05-05 | 2022-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-05 | 2022-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-05 | 2022-06-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-05 | 2022-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-05 | 2022-06-02 | 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 | 2022-05-03 | 2022-06-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-23 | 2022-01-24 | Y |
| 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 | 2020-01-29 | 2020-03-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-29 | 2020-03-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-29 | 2020-03-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-29 | 2020-03-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-29 | 2020-03-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-29 | 2020-03-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-01-29 | 2020-03-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-25 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-05-03 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-01-29 | Not Fixed | N |
