Crown Haven Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF627Jul 3, 2025

  Based on record review, and staff, resident, family member, Medical Director and Adult Protective Services (APS) Social Worker (SW) interviews, the facility failed to provide a safe and orderly discharge for 1 of 3 residents reviewed for discharge (Resident #88). Resident #88 was being treated in the facility with Chlordiazepoxide HCl (a medication used to treat the symptoms of alcohol withdrawal also known as Librium) for a known history of alcohol abuse and received a dose a short time before exiting the facility on 5/18/25 at approximately 10:51 AM. […]

• Immediate jeopardy, isolatedF580Dec 13, 2023

  Based on record reviews and responsible party, staff, and Medical Director interviews, the facility failed to notify Resident #1's responsible party (RP) that Resident #1 had low blood sugar levels from insulin administration and the insulin was discontinued on 07/21/23. The insulin was prescribed for Person #2 (potential new admission from the same skilled nursing facility with same first and last name as Resident #1). Resident #1's RP stated if he had been notified in July about the administration of the insulin he would have asked to speak to the Administrator and the Medical Director and informed them Resident #1 did not have a diagnosis of diabetes. […]

• Immediate jeopardy, isolatedF620Dec 13, 2023

  Based on record reviews and staff interviews, the facility failed to implement their Admissions Policy and Procedure and verify the identity of a cognitively impaired resident when he was admitted to the facility with paperwork from the discharging skilled nursing facility for Person #2 (potential new admission with same first and last name as Resident #1). As a result, Resident #1, who did not have a diagnosis of diabetes, was administered 3 doses of long-acting insulin, and experienced 3 three low blood sugar levels before the insulin was discontinued. In addition, Resident #1 received an anticoagulant, aspirin, a diuretic, and a medication used to treat hypothyroidism from 07/17/23 until 09/15/23 prescribed for Person #2. […]

• Immediate jeopardy, isolatedF760Dec 13, 2023

  Based on record reviews and family member, staff, Nurse Practitioner and Medical Director interviews, the facility failed to prevent significant medication errors when a. Resident #1 was administered medications prescribed for Person #2 (potential new admission with same first and last name as Resident #1). Person #2's information and medication orders were entered for Resident #1 in error on 7/17/23 and this was not discovered until 9/15/23. Resident #1 did not have a diagnosis of diabetes and was administered 3 doses of long-acting insulin and had three low blood sugar levels before the insulin was discontinued on 07/21/23. In addition, Resident #1 was administered an anticoagulant, aspirin, diuretic, and a medication used to treat hypothyroidism for which he had no diagnoses to treat. […]

• Immediate jeopardy, isolatedF757May 25, 2023

  Based on record review, staff, Consultant Pharmacist, Nurse Practitioner, and Medical Director interviews the facility failed to monitor the use of Levemir with finger stick blood glucose levels as ordered by the physician for 1 of 3 residents reviewed for unnecessary medications (Resident #7). Levemir is a long-acting insulin injected under the skin. On 05/14/23 Resident #7's family identified a change in the Resident's condition and requested Nurse #2 check the resident's finger stick blood glucose level. Resident #7's finger stick blood glucose level reading was HI. The HI blood glucose reading indicated severe hyperglycemia (much higher than normal blood glucose levels). […]