Biltmore Haven Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Biltmore Haven Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF607Jan 16, 2024

  Based on record review and interviews with the resident and staff, the facility failed to follow their abuse policy for protection after Resident #52 reported on 12/28/23 that Nurse Aide (NA) #1 had been providing her with methamphetamine and syringes. The facility failed to suspend NA #1 and allowed her to work her scheduled shift on 12/28/23 from 7:00 PM to 7:00 AM on 12/29/23. This deficient practice had the high likelihood of serious adverse outcome for 10 residents with history of substance abuse which included Resident #52. […]

• Immediate jeopardy, patternF689Jan 16, 2024

  Based on record review, observations, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to discuss with Resident #52 the presence of many needles found in her possession at the hospital, monitor for illegal substances in her room and supervise Resident #52 for triggers of illegal substance abuse for a resident with a known history of substance abuse. Resident #52 was found with many needles in her room while in the hospital on 9/22/23. On 10/5/23, Resident #52 was sent to the hospital after a sudden onset of lethargy, low oxygen saturation and increased heart rate. Hospital staff documented suspicion of illicit drug use. […]

• Immediate jeopardy, patternF835Jan 16, 2024

  Based on record review, observation, and interviews with resident, staff, Nurse Practitioner, Medical Director and Police Officer, the facility failed to provide effective leadership and implement effective systems to manage and supervise a resident with a history of substance abuse after syringes were found in Resident #52's room and protect all residents after Resident #52 reported Nurse Aide #1 was providing her with methamphetamine and syringes. This failure had a high likelihood of affecting other facility residents. Immediate jeopardy started on 10/5/23 when after observing drug paraphernalia in Resident #52's room the facility's administrative team failed to identify the seriousness of the situation and put effective systems in place. […]

• Immediate jeopardy, isolatedF684May 12, 2026

  Based on record review, resident, staff, Nurse Practitioner and Medical Director interviews, Driver #1 failed to have Resident #1 assessed for injury by a qualified medical professional prior to moving the resident following a fall in the transportation van. Resident #1's wheelchair tipped over backwards with Resident #1 in the wheelchair resulting in the resident hitting his head on the van floor. Driver #1 lifted Resident #1 while in his wheelchair back to the upright position and returned to the facility without calling Emergency Medical Services for assistance. Driver #1 was not qualified to provide a comprehensive physical assessment to determine if Resident #1 had sustained any injuries. […]

• Immediate jeopardy, isolatedF689May 12, 2026

  Based on observations, record review and interviews with resident, staff, Nurse Practitioner and Medical Director, Driver #1 failed to provide safe transportation on 03/02/2026 when Resident #1's lap belt and front retractor tie-downs (retractor tie-down systems are often called a 4-point securement system) were not correctly applied per manufacturer's instructions leaving Resident #1 not fully secured while in his wheelchair in the facility transport van. Resident #1, who only had one leg, and no hands, was being transported to a medical appointment by Driver #1. As the vehicle accelerated from a full stop at a traffic light, Resident #1's wheelchair tipped over backward with Resident #1 in the wheelchair resulting in the resident hitting his head on the van floor. […]