Haven Hall Health Care Center

In the surveyor’s words

From the most serious findings on record at Haven Hall Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 24, 2023

  Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision to prevent Resident #1, who had severe cognitive impairment, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 Resident #1 was able to obtain the unsecured wireless transmitter from the unmanned reception desk at the facility's front door at approximately 11:00 AM on 8/13/23 and use the transmitter to unlock the front door and exit the facility. The facility staff were unaware of Resident #1's absence until approximately 11:19 AM, when a member of staff returning from lunch observed the resident standing at a busy intersection approximately 540 feet from the facility. […]

• No harm, potential for more than minimal, widespreadF851Apr 2, 2026

  Based on record review, staff interviews, and facility policy review, the facility failed to ensure the Payroll-Based Journal (PBJ) report for the October 1 through December 31 reporting period was submitted accurately and within the required Centers for Medicare & Medicaid Services (CMS) timeframe for one (1) of four (4) quarters reviewed. Findings include:A record review of the policy, Reporting Direct Care Staffing Information (Payroll-Based Journal), revised August 2022, revealed, Policy Statement Direct care staffing is reported electronically to CMS (Centers for Medicare and Medicaid) through the Payroll-Based Journal System .Policy Interpretation .10. […]

• No harm, potential for more than minimal, widespreadF851Oct 31, 2024

  Based on interviews and Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll-Based Journal (PBJ) data, containing staffing hours for the appropriate care of residents, was corrected before submission to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters in 2024. 3rd (Third) Quarter Findings Include: A review of the facility policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), revised August 2022, revealed, . […]

• No harm, potential for more than minimal, patternF658Apr 2, 2026

  Based on interview, record review, and facility policy review the facility failed to ensure residents received care and services in accordance with professional standards of practice and physician oversight. Specifically, the facility failed to clarify and obtain appropriate physician guidance regarding administration of blood pressure medications prior to dialysis and failed to follow safe medication administration practices, resulting in the resident receiving medications that had the potential to cause hypotension during dialysis one (1) of (1) residents reviewed for dialysis care. Resident #14Findings Include: Record review of the facility policy Administering Medications dated 2001 revealed Medications are administered in a safe and timely manner and as prescribed . 8. […]

• No harm, potential for more than minimal, patternF684Apr 2, 2026

  Based on observation, interviews, record reviews, and facility policy review the facility failed to provide complete perineal (peri-care) for one (1) of two (2) residents observed for incontinent care. Resident #26Findings Include:Record review of the facility's policy Cather Care, Urinary dated 8/2022 revealed, .Routine Perineal Hygiene: 1. Wash basin, soap and water and washcloths; OR 2. Bathing wipes 3. Towels;4. Bed protector.Steps.1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the basin over half (1/2) full of warm water (or if using bathing wipes, open the package). 4. Place the wash basin or wipes on the bedside stand within easy reach. 5. Put on gloves. […]